series RET/6/5 - CASE NOTES

Identity area

Reference code

RET/6/5

Title

CASE NOTES

Date(s)

  • 1796 - c 2000 (Creation)

Level of description

series

Extent and medium

610 boxes

Context area

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Content and structure area

Scope and content

Chronological Arrangement of the Case Notes

From 1796 up to the First World War period, the case notes of patients were, broadly speaking written into case books in chronological order by date of patient's admission. Each case was also given a consecutive admission number, starting with patient number 1 on 13 June 1796.

Patients admitted more than once had a new number allocated each time.

However, in practice, the arrangement of the case books was complicated in various ways, and the first volumes in the series (RET 6/5/1/1A - 6/5/1/3) are particularly confusing: see notes under each entry.

From RET 6/5/1/4 onwards, the series is more straightforward, with each volume covering about three years or more and arranged in chronological order by admission date/patient number.

However, the case books covering the period c 1830 - 1870, RET 6/5/1/4 - RET 6/5/1/9, were subsequently used, (perhaps as part of an economy drive!), for the insertion of later notes into each volume. This can make the sequence within these volumes confusing, so the list below gives the patient reference numbers contained in each volume. This erratic insertion of notes into the case book took place between 1855 and 1873; after this date, the notes are entered in a straightforwardly chronological manner once more.

From the 1880s males and females are covered by separate volumes.

After 1890, voluntary boarders could be accepted as patients, and these were entered into separate case books, RET 6/5/2/1-2, although the volumes in the main series also include some voluntary boarders' notes (and in addition, some voluntary boarders' admission forms and notes are included in the patients' correspondence files, RET 6/20).

The original numbering of case books ends with Case Book XXIV (RET 6/5/1/24) in 1915. After this date there was a major change in the way notes were kept: instead of being written into case books in admission order, notes on patients were kept in loose leaf form and only later bound into volumes when they were arranged by date of discharge or death. At larger asylums notes were bound into annual male and female 'discharge' and 'death' volumes. At the much smaller Retreat, however, volumes covered periods of years, with discharges and deaths filed together.

RET 6/5/1/256 - 6/5/127 are in this format. Within the volumes patients' notes are bound in alphabetical order. The Retreat converted to the modern system of individual patients' case folders in 1935. RET 6/5/4 are case note folders for the period c 1924 onwards (there was an overlap in the dates during which the Retreat converted from case books to case folders).

Notes for patients resident at Throxenby Hall (leased by the Retreat between 1903 and 1924, see RET 7/3) are included in the later volumes of case books although there are also some separate notes for Throxenby Hall patients at RET 7/3/5. There are also some separate notes for patients at Millfield, another Retreat annexe at Hull Road, York, at RET 7/2/41.

Admission papers for patients in the case books up to c 1900 can be found at RET 6/1. Admission papers, nursing notes etc for patients after c 1900 can be found, along with correspondence, in the patients’ correspondence files (RET 6/20).

Dr Bedford Pierce and succeeding Retreat psychiatrists also saw, as independent consultants, their own private patients in consulting rooms at Leeds, at the Retreat, and elsewhere. Case books and/or correspondence relating to psychiatrists' private consulting practice is at RET 8/4.

Internal Arrangement of the Case Books

Although most of the series of case books is arranged in chronological order by date of admission, the sequence within a volume is often interrupted by the insertion of 'continuation notes' on patients with earlier admission dates/patient numbers. This is because when the set number of pages originally allotted for a patient's notes ran out, these notes were either continued on the next available blank page, or were sometimes continued at the back of the book, or were sometimes slotted into any available blank space at the end of other completed patients' entries. Notes of very long stay patients might in this way run from volume to volume, sometimes being included in several books (cross references are generally given). Once case notes began to be kept in loose leaf form and bound into volumes after the patient had died or left, this problem of keeping patients' notes together was largely overcome.

Sometimes the notes of patients who were being admitted for a second or subsequent time were written in after the end of the notes of their first or earlier admission, even though the patient was allotted a new admission number. (The admission register will note whether an admission was a first or subsequent one). This practice accounts for some of the apparent gaps in the chronological and patient numbering sequence in the case books (but some of the gaps in numbering is due to the erratic entry of notes into the case books during the period c. 1855 - 1873 - see note on chronological arrangement of case books above).

While the page numbers of the entries in Case Book 1 (RET 6/5/1/1A) are cross referenced from the first admission register, RET 6/2/1/1, subsequent admission registers do not reference case book page numbers.

Finding the Case Notes of Patients

Name of patient, patient reference number and date of admission (of first admission, if admitted more than once) should all be noted from the admission registers, and should be sufficient to track the entry or entries in the case books

Finding the case notes of individual patients within the volumes is helped considerably by the fact that each volume contains a name index at the front - this can occasionally be unreliable.

There are also consolidated index volumes to the case books, covering patients in case books 1 - 23. These are listed at RET 6/5/3

Accruals

System of arrangement

Conditions of access and use area

Conditions governing access

Access to some material is restricted under data protection laws. Restricted items are at RET 6/5/1/23, 6/5/1/24, 6/5/1/24A, 6/5/1/25, 6/5/1/26, 6/5/1/27, RET 6/5/2/2, RET 6/5/4, and RET 6/5/5.

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