Taking and Keeping: A Note on the Emergence and Function of Hospital Patient Records

Abstract

The paper attempts to reconstruct the emergence and the changing function of medical recording in psychiatry based on the records of the Charité Hospital in Berlin. The development of patient documentation was influenced by three aspects: firstly the earliest documents, from the early 18th century, became increasingly structured as diverse office technologies entered the hospital's ward at this time. Secondly while medical recording in the narrow sense remained private, the regular and formalized reporting system in the hospital wards of the Charité became an important part of clinical education. Finally the growing scientific role of the records became evident with the reorganisation of the hospital record into a double filing system in the late 1870s, thus allowing the clinicians to use and select patient files systematically for research purposes.