How were hospital records kept in the 1750s?

Answer 1

There were NO hospitals in the 1700s and NO patient records.

Medical care was done in person's homes (at home) and on battlefields.

By the mid to late 1800s, "county homes" came into favor.

By the late 1800s, "sanitoriums" were in use for minor psychiatric cases and TB, mostly.

By the late 1800s, "county homes" served as warehousing for dementia (such as resulting from STDs), brain damage, elderly unable to care for themselves, stroke and TIA patients, and psychiatric patients, as well as persons born with brain damage or birth defects. At the same time, some "homes" also contained otherwise healthy orphans, or "incorrigible" teens whose parents couldn't control at home.

By the very late 1890s and turn of the century, doctors and prosperous, educated citizens began to establish hospitals. Very little was written down about patients. Doctors were mostly paid with goods-- a hen, a cow, a new saddle, etc. Doctors made medicines as they needed, for each patient -- if a medication was known. Most meds (like now) came from grinding of certain plants or roots. "Treatments" were often by guessing and some prior experience.

Record improvements occurred between 1900 and 1950s, but still had no specific types of information. Doctors made notes similar to those kept in a doctor's office.

After World War II and subsequent wars (Korean, Vietnam), doctors recognized the importance of more precise record keeping. But, it still varied from doctor to doctor, or hospital to hospital.

Insurance came along after more workers and industries became "unionized". Insurance carriers had a lot to do with demanding a more organized and systematized method of "recording" (making a record) of patient's problems and treatments.

At the same time, doctors had been developing precise ways from the earliest days of medicine to the 1960s (and beyond) to use the same criteria to describe a certain condition or illness. Assigning of a 'diagnosis' became much more important to justify to insurance companies the need to pay for services rendered. For example, in respiratory conditions, a common cold requires much less medical intervention than a person with acute pneumonia. So doctors began to be very precise in the "label" (diagnosis) they gave, and in documenting the treatment given.

Through the 1960s and 1970s, hospitals were still fairly closed systems-- more authoritative, secret,, veiled in mystery, kept behind closed curtains around the bedside. But, by the 1980s, many factors including insurance companies began to question how and why hospitals functioned or operated within the closed system. Insurance companies had quickly learned the true costs of everyday actions at hospitals, for example. No longer could a doctor charge a large fee to one patient, and a small fee to another patient-- when both had the same illness, disease, and care. Through the mid-1970s, patients only had one choice: go to the hospital. Even childbirth-- always done at home up through the 1920s-- had solely become "hospital cases".

By the 1980s, no longer did patients have just one choice. They now could choose to stay home, in part because of changes in how insurance companies paid (or didn't pay). The mandatory 7-day hospital stay after certain conditions, such as childbirth, became at the most 3 days. (Now, it may be 1 to 2 days.) Mandatory stays after surgeries reduced from 7 to 14 days in the hospital, to no longer than 5 days.

But, still, medicine and medical insurance continued to evolve, and the "patient chart" or medical record became the primary tool for both. Insurance companies questioned procedures, surgeries, treatments-- and their costs! Insurance companies regularly reviewed medical charts and if a doctor failed to chart properly, the doctor and hospital often did not get paid.

More and more, services were offered as out-patient. Hospital stays became short. Governing bodies over physicians and nurses developed clear rules, wording, and methods for how to chart a patient record. No more could a patient go to the hospital "for a rest", as was common in the late 1890s.

Now, hospital records are mandated ways of maintaining a written record of what transpired from the first minutes a patient enters the hospital or ER. A "patient chart" is not only a medical record, but in some ways is also a legal record. In the USA, patient records must be kept for 7 years -- which is 6 years beyond the legal statue of limitations to file a malpractice lawsuit. In the United Kingdom, the patient record is kept from birth and never purged, deleted, or destroyed. I do not know Canada, Mexico, or other overseas countries, and their laws for how long a medical record must be kept probably vary.