Friday, 11 July 2014

Charting neurosurgery

As previous Dott project blog posts have discussed there is a wealth of information to be found in the individual patient case notes and they are made up of a variety of documentation from which specific details are recorded and entered into the catalogue. A lot of what we require for the catalogue entries can be found in typed case summaries or correspondence which will give details about the patient, their condition, how they were treated and the outcome of their treatment, but other documents such as clinical charts provide additional detail such as the type and dosage of medication the patient received and detailed monitoring of their physical condition.
LHB40 CC/24/PR2.9393

LHB1 CC/24/PR2.9393
The volume of material comprising each case note can vary greatly, often depending on the patient’s condition and how they were treated.  The clinical charts tend to be found at the very back of the case note and in some instances were surgical treatment has been undergone there can be a large volume of charts detailing the patient’s condition prior to and after their treatment.
LHB1 CC/24/PR2.9356
There are several different types of chart that appear in the case notes including those which record temperature, pulse, blood pressure, respiration,  fluid balance, medication administered, body charts and eye charts. I have selected some of the different clinical charts I have come across in the last few weeks from case notes of patients who were treated in the Department of Surgical Neurology in 1950 and 1951.
LHB1 CC/24/PR2.9364

LHB1 CC/24/PR2.9526
These records are a valuable part of the case notes as they can provide important detailed information that may not be included in case summaries about their symptoms and condition and showing how patients were treated and how they reacted to treatment.


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