Hospital Records and Statistics
The very first record available on any patient in the University Hospital is dated October 5, 1881. This is Case No. 1, which is listed in a leatherbound book and is the first of a series of records maintained by the Department of Gynecology, at that time under the direction of Dr. Edward Dunster. This book is entitled "Gynecological Clinic Record, Medical Department" and contains the records on patients seen in that department from October 5, 1881, to December 5, 1882.
The history sheets in this record book were outlined forms calling for routine statistical information about the patient, such as age, marital status, number of children, age of oldest, and age of youngest. Ten lines were reserved for enumeration of the symptoms and three lines for the physical examination. Space was also left for a rather detailed gynecological history. At the bottom of the sheet was a space for diagnosis. Opposite this page was a ruled sheet for recording treatment.
The diagnosis noted on this first patient was menorrhagia, and on the treatment sheet under date of October 26 is a note, "No abnormal condition of the interior of the womb. Mucous lining removed with curette." Under date of November 8 appears another note — "Uterine mucous lining again removed." Patient No. 3 was diagnosed "vesico-vaginal fistula traumatic." On the treatment sheet under date of October 28 is noted: "Fistula closed; eight sutures (silver) (one horse hair)"; November 4: "Stitches removed; operation incomplete due to neglect after operation (anesthesia, ether). Patient left Hospital." January 17: "Returned; second operation successful. Patient dismissed." These examples are typical of the extent to which examinations were written up and operations described at that time.
Record systems were apparently established about the same time in other departments, each one maintaining its own separate case number for the patient and retaining in the department all available information learned.
It was interesting to find a sheet in this original book entitled "Examination of the Urine." This contained statements as to the physical characteristics including reaction, color, and specific gravity. After this, was chemical examination, which called for urea, phosphates, bile, albumen, urates, and sugar. The microscopical examination called for crystals, anatomical elements, casts, and, finally, other morphological elements. At the end were reserved a few lines for pathological indications.
It is difficult to determine just when indexing of diagnoses was actually begun; however, shortly after the history forms were established, these various clinical departments formulated their own individual systems of recording diagnoses and operations. No uniform system was used, some preferring to list the diagnoses alphabetically, and some Page 996by numbers. Operations were recorded in a similar manner.
Shortly after the University Hospital was opened in 1925, Dr. Harley A. Haynes, the Director, obtained the services of Miss Florence G. Babcock, at that time record librarian of the Peter Bent Brigham Hospital in Boston, who assumed charge as Record Librarian. At the same time the various departments were persuaded to submit all information pertaining to a given patient to a central record room, where it could be included in a unit patient record. In addition to including the various examinations made by different departments on any one patient, the record thenceforth was to include all X-ray reports, pathology reports, bacteriology reports, and other special laboratory procedures. On admission to the Hospital, each patient was to be given a registration number, and this was to be employed uniformly by all the departments in which the patient was seen. Coincident with the formation of the unit system, the Hospital staff adopted the Massachusetts General Nomenclature of Disease as the standard nomenclature to be used in the Hospital.
The staff doctors were then requested to list the various diagnoses and operations on the front sheet of each patient's unit-record, and these in turn were recorded on special cards in the central record room by trained record librarians. For reference purposes the diagnosis, secondary diagnosis, name, operated or not operated, registration numbers, service, sex, age, registration date, date of death, date of previous registration, and classification were recorded.
With this new system it became possible for the doctors to obtain for study all cases of any one diagnosis seen in the University Hospital, regardless of who made the diagnosis. In addition, all information pertaining to a patient could be obtained in one record.
In 1933 the executive staff of the Hospital entertained the advisability of establishing a large cancer clinic. In the course of developing this clinic various methods of recording routine statistical information were studied, and the so-called Hollerith punch card system was adopted. Dr. H. M. Pollard, at that time Instructor in the Department of Internal Medicine, was appointed to take charge of establishing this unit for hospital statistics. He was succeeded July 1, 1937, by Dr. Isadore Lampe, Instructor in the Department of Roentgenology.
Space was made available for this new unit on the ground floor of the University Hospital, and adequate tabulation machinery was obtained. From July 1, 1934, all routine statistical information relating to patients, and all their diagnoses and operations, have been recorded on punch cards. This includes the patient's registration number, age, race, status, classification, service, residence, all diagnoses and operations, Kahn report, death, autopsy, X-ray report, pathology report, and condition on discharge.
The nomenclature employed beginning July 1, 1934, was still the Massachusetts General System, but diagnoses were given numbers which could be utilized in the punch card system, and in so doing, space was made available for the addition of new diagnoses.
A doctors' study room was built in connection with the Statistical Unit and furnished with comfortable chairs convenient for studying records. All doctors studying cases utilize this room, so that records are not distributed to various offices.
This whole method of tabulation for hospital records is proving highly satisfactory and serves as a great stimulus to the staff physicians making careful and accurate statistical analysis of various diseases, forms of treatment, and results.
Page 997The records themselves have been improved by typing all inpatient histories and physical examinations. Outpatient notes are still made in longhand; case summaries, and in some instances progress notes, are typed. An effort is made to have all statements relating to types and results of treatment as specific as possible so that the information may be made available for study at any future date.