Hess, Volker/Sophie Ledebur: Taking and Keeping. A note on the emergence and function of hospital...

Taking and Keeping: A Note on theEmergence and Function of HospitalPatient RecordsVolker Hess and Sophie Ledebur

The paper attempts to reconstruct the emergence and the changing function of medical

recording in psychiatry based on the records of the Charite Hospital in Berlin. Thedevelopment of patient documentation was influenced by three aspects: firstly the earliestdocuments, from the early 18th century, became increasingly structured as diverse office

technologies entered the hospital’s ward at this time. Secondly while medical recording inthe narrow sense remained private, the regular and formalized reporting system in the

hospital wards of the Charite became an important part of clinical education. Finally thegrowing 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 cliniciansto use and select patient files systematically for research purposes.

In the early modern period, physicians were already taking notes at the bedside.1 Inspite of this, recent studies have claimed that patient-centred recording, loose files

and pre-printed forms were not introduced until c.1900. Barbara Craig, StefanTimmermans and Marc Berg, and Joel Howell have argued that this process wasclosely related to office technologies developed at the turn of the century.2

This premise is right – in principle. But in fact bureaucracy had already influencedmedical recording since the founding of the first hospitals in medieval Europe.3

Administrative techniques may not be as old as medicine but they emerged alongwith the rise of the modern hospital. Formalized patient documentation can be found

from the early 18th century, and pre-printed forms and loose patient files werealready used in hospitals in the early 19th century,4 nearly 100 years earlier than

recent studies have claimed. We will substantiate this claim in the first part of thepaper. In the second section, we will argue that the close relationship between

Correspondence to: Volker Hess and Sophie Ledebur, Institute for the History of Medicine, ChariteBerlin, Ziegelstraße 10, 10117 Berlin, Germany. Email: [email protected],[email protected]

Journal of the Society of ArchivistsVol. 32, No. 1, April 2011, 21–33

ISSN 0037-9816 (print)/ISSN 1465-3907 (online) � 2011 Archives and Records AssociationDOI: 10.1080/00379816.2011.563102

administrative routines and recording bedside observations was productive ingenerating a disciplined and specialized knowledge. Recording technologies did not

passively serve the will and intentions of administrators, surgeons, and clinicians; incontrast, they played an active role in the development of medical knowledge. That is

the broad scope of the ongoing research project.5

As Barbara Craig has shown, one needs to look at the methods of administration in

order to follow the first traces of patient-related recording. Our case study will focuson recordkeeping in the Charite hospital in Berlin which may illustrate the rise of new

paper technology.6 Founded as pest lazaretto (hospital for epidemic diseases) in 1710but left disused, the Charite was rededicated as a general hospital and used for thetraining of prospective military surgeons in the 1720s.7 When the Berlin University

was established in 1810, the hospital was subsequently transformed step by step into auniversity teaching hospital in the following decades. Because we cannot capture the

story in its entirety as it spans nearly two centuries, we want to focus on three stepsthat seem to be decisive for the development of patient recording. First, we will follow

the spread of office techniques to the hospital wards where they infiltrated the dailyroutines of physicians and surgeons. Obliged to assist the hospital administration, the

medical staff became familiar with new ways of writing. Filling in tables and listsmediated skills and habits originally not linked with bedside observation.

The second step focuses on the 1820s when administrative recordkeeping wasgradually integrated into the medical training. Replacing traditional ways of medicalrecording, the administrative forms and schemas became a second-hand function

which gave them a new role.Lastly, we will discuss changes in filing as the third key step. At the end of the 19th

century, clinicians became aware of the medical importance of the patient record forresearch and teaching. To archive the patient records for their own purposes, the

physicians developed a system of double-filing, which we present in the third section.

Administrative Beginnings

In 1737, the first instruction tried to organize the surgeon’s work at the Charite and

also to define the daily tasks:8 ‘In the morning, in all wards, after examining the statusof the patient, He [the surgeon] has to write at the provided blackboard what each

patient, especially those who were seriously affected and needed special diets, will getfor lunch in order of the bill of fare’.9

The first part of the order –the examination– is good medical practice as it still istoday. The second –filling in the blackboard at the front of bed– assisted the

administrative work of the hospital’s economy. Food was the largest expenditure inthe hospital’s budget which may explain the dominant role of the diet order. Each

morning the surgeon also had to fill in the so-called deficit slip so the kitchen wasable to prepare the right number of lunch portions properly. At the end of the week,the surgeons also had to summarize the daily report in another form which listed the

number of portions applied per week. This recording could hardly be counted as a

22 V. Hess and S. Ledebur

Hippocratic art. Instead, the daily diet report and deficit slip represented four crucialsteps in medical recordkeeping.

First, the kitchen report prompted the writing down of the medical examinationbecause the diet prescriptions testified to the state of the patient’s health. Secondly,

the bedside observation –one of the central elements of the medical art– becameroutine and permanent by filling in the daily deficit slip. Thirdly, these slips merged

book-keeping with medical thinking. Contemporaries knew ‘defektieren’ (transla-table as ‘deficit calculation’) as the technical term defining and updating the

incoming and outgoing costs, the purchase and distribution of food portions. So theroutine of daily reporting initiated a kind of medical recording as an element ofhousekeeping as well as bringing some degree of formalization to the process.10

The schemes introduced framed the daily examination in a defined and prescribedmanner and procedure. Exercising these techniques represented the fourth crucial

step, which might provide for the further development of forms. The form inFigure 1 illustrates how physicians were trained in administrative work: to complete

the form of ‘diet prescriptions’, the surgeon had to select the right prescription fromthe ready-made list. First he had to assign it to the patients, then he had to extract the

portions by going through all the prescriptions and marking the relevant entries, andfinally he had to copy the selected entries into the right field of the scheme. To

Figure 1 Schema pro mense (ca 1750). Schema for announcing the daily diet to thehospital kitchen, Charite Berlin (UAHU, Akten der Charite-Direktion, 1725–1945, No180, o.P. By permission of the Universitatsarchiv der Humboldt-Universitat)

Journal of the Society of Archivists 23

summarize: what the surgeons exercised on their daily ward rounds was a lesson inearly modern office technology.

This kind of book keeping had nothing to do with medical art or science. Incontrast to the sophisticated kitchen economy, the instructions for medical recording

remained vague. The order obliged the surgeons to report on the nature andconditions of the patients ‘so often as needed’ but it was not regulated how to do this.

Reporting ‘cannot be dictated precisely but remains up to their conscience how theycan take responsibility before God and the suffering and helpless poor’.11

Kitchen and book-keeping were one way for office technologies to enter thehospital ward. Another one was political arithmetic, namely the proto-statistics usedin early modern bureaucracy. Since the late 17th century, baptisms, marriages, and

deaths were counted and compiled in large tables. The hospitals would also take partin these governmental efforts. At the Charite, the model of the parochial

administration was translated into a special schema included in the ward journals.Even if such duties seemed to serve medical functions, they actually didn’t. The birth

register and mortality bills for the Charite were the same for the sexton which fulfilledthe consistory’s paperwork. In the same way, hospital surgeons were also obliged to

compile the data using General Tables in which they strictly noted how many patientsentered and left the hospital, what the effects of the treatment were, and so on.

Producing tables was a lot of work for which interns were recruited. At the end of the18th century, physicians and surgeons obviously knew how to fill in schemas andforms. They produced a weekly summary of the treated patients, a monthly report on

the weather, epidemic diseases and their appropriate treatments, and also the patientlist including those who were treated and those who died per quarter.

With forms and schemas, kitchen economy and political arithmetic established aregular, structured and formalized documentation system in the hospital wards of the

Charite in the 18th century. Surgeons and physicians learned not only how to observe,prescribe and dress wounds, but also administrative techniques by way of making

tables, using forms, and filling in schemas –not to mention the discipline needed forthe completion of this bureaucratic paperwork. These skills became more and moreimportant for prospective military surgeons as well as for future medical officers, but

were not necessarily linked to medical purposes.What was the impact of these techniques that physicians had learned in

administration? What did the forms and schemas change when used at the bedside?This question is crucial because tables were not only introduced into medicine via

hospital practice. There were numerous ideas in the eighteenth century for improvingpatient observation through better recordkeeping. Figure 2 shows one example of

these efforts, a schema published by Francis Clifton in 1731. The form had sixcolumns: one for age, sex, occupation and so on, two for dates, one large column for

recording the symptoms, and two for prescriptions and events. However, we don’tknow of any case in which this table was used. We do not find such forms until thelate eighteenth century, in the context of military hospitals in France as well as for the

purposes of clinical training in Scotland and Germany.12


At the Charite hospital, such forms were already in use. In 1799, surgeons wereinstructed to record their observations ‘with the known schema’ as shown in Figure 3.

In the 1820s, the simple table had grown to a preprinted folded double page: at thetop of the first page were fields provided for administrative entries, followed by a long

column used for daily entries. The second page offered further space for thechronology of diseases which could be continued on additional sheets. Without

question, Figure 3 represents a modern loose file patient record:13 this type of pre-printed form remained in use until around 1900.14

Ways of Writing

Training in office techniques can be regarded as one element of the disciplinaryregime which transformed the hospital into a modern medical institution. With pen

and paper, the formalized recordkeeping linked the different operating spheres(admitting office, accounting, kitchen, home-keeping, pharmacy, medical training,

etc).15 It interlinked the specialist wards and clinics which were increasinglybecoming separated into their own buildings. In 1835, the psychiatric department

moved to the so-called ‘New Charite’, within which were also housed the syphiliticsand sick captives from the state prisons. In 1864, the department was expanded withthe establishment of a neurological department. The new ward was separated from

the department for internal medicine and it was situated in the so-called Old

Figure 2 Schema presented in Clifton, Francis: The State of Physick, Ancient andModern, Briefly Consider’d: with a Plan for the Improvement of It. London 1732, herethe figure from the French translation (1742). By permission of the BibliothequeInteruniversitaire de medecine, Paris


Figure 3 Hospital form for taking a patient history. The so-called Journalblatt is one ofthe earliest kinds of hospital patient records we know. Shown here is the front of thefolded sheet that doubles as a patient file folder. Charite Berlin, 1825. GeheimesStaatsarchiv Preußischer Kulturbesitz (GStPK), 1. HA 76 VIII A Nr. 2182 Acta betr. dieangeblichen Heilkrafte des Dienstknechts Grabe, Vol. 2. By permission of the GStPK


Charite –a considerable distance from other parts of the clinic. The patients wereoften transferred not only between both houses but also inside the department itself

between the wards for delirious, epileptic, and lunatic patients. The clinical ensemblewas enlarged once more in 1871 when the outpatient department for nervous

disorders was founded.The spatial and disciplinary differentiation went along with the multiplication of

paper work. Already by the 1830s, the bureaucracy reached its first climax withformalizing the administrative procedures. Six preprinted forms were introduced to

register and admit patients with all the necessary information. Transferred from theadmitting office to the appointed ward, the patient was also accompanied with acouple of sheets in order to start the journal and the treatment sheet with the correct

data. All forms were also transferred when the patient had to move to another ward.After dismissal, all documents went back to the admitting office where the forms were

filed to a folder and registered for accounting purposes.Most of the paper work was given over to the military interns who spent the last

year of their course in the Charite to practise their medical skills. In the wards, theprospective military surgeons not only had to take care of patients’ treatment, but

also were often the only personnel who were competent in writing and counting. Inthis way, the emerging bureaucracy also merged with educational purposes. While

medical recording in the narrow sense remained private, the keeping of theadministrative forms was integrated into clinical training. In the 1830s, the leadingphysicians were officially obliged to ensure on a weekly basis that the interns were

keeping the patient files properly. The resulting chorus of complaints about foulnotes, incomplete observations, and missing records illustrates the increasing

significance of recordkeeping in the curriculum. The forms might have had nomedical function at the beginning. From using them day-by-day, however, the pre-

printed forms began to replace other forms of taking notes. The private case-bookwas substituted step-by-step by the ward and patient journal. Even the blackboard

sheets which we have already seen in the early 18th century were integrated into theclinical ‘Aufschreibesystem’.16

This system of recordkeeping comprised three elements: first the treatment sheet

upon which the bedside observations were noted, including the impressive symptoms inthe course of the disease, and the medication prescribed each day. Attached ‘together

with the diet prescription’ at the blackboards (‘Kopftafeln’) over the patient’s bolster,the treatment sheet gave also an overview for the attending doctors by co-ordinating the

differentiation of labour (kitchen, diagnostics, treatment, teaching, etc). It represented aprotocol in both senses of the word: the treatment sheet logged the activities at bedside

on the one hand, and, on the other, the daily recording enfolded also prescriptivefunctions by anticipating the ‘to do’ list of the hospital during the working day.17 One

obligatory step was copying which bound together the first and second elements of theclinical ‘Aufschreibesystem’. Each evening, the interns spent hours transferring the noteson the treatment sheets to the journal sheet (Journalblatt) of the patient’s file. Time was

often not enough for the young doctors to add their own observations to the formal


notes. Completing the patient history meant to translate the pure facts into a narrativedescribing the course of the disease. In contrast to the former case-books, the patient

files also included the administrative data as well as copied certifications, letters fromother physicians, and –in the late nineteenth century– records of diagnostic

measurements. Ideally, the patient record represented the complete history of thedisease (‘Krankheits-Geschichte’) –the modern form of the historia morbi.18 The third

element was the registry that included all registers kept in the admitting office.Numerous orders and directions were given for returning the files on time, avoiding

their misplacement, and writing clearly and properly in case of use by other authorities.The patient records had to be established, at the latest, by the third day of admission.The clerks in attendance not only checked the documents for completeness, they also

consolidated the file by adding the forms needed for administration. The completefolders were sorted in two ways –the simple cases without reimbursement of costs were

stored alphabetically, the other ones were filed into pigeon-holes to start thecomplicated process of invoicing the treatment costs. Each procedure was mirrored

by enlisting the ‘course of files’ in separate registers. There was one for obtaining thecash in advance, the list of the files filtered for correspondence, and the one needed for

official purposes–but not forgetting the mother of all registers, the main ledger in whicheach patient was recorded at the time of admission by consecutive numbering per year.

The admission number represented by an ID was used in all schemas, registers, andother documents. So the admission number allowed one to follow the cross-linkednetwork of single departments, and movement of the patients between them. The

patient record invented in the 1820s was born out of the spirit of bureaucracy andcultivated hospital administration. But the medical use of these records was much less

and only limited to educational purposes at first.

Double File System

Most of the patient files passed down today originated from the psychiatricdepartment. All records from other departments as well as most parts of the registryhave disappeared. The reason why the psychiatric files in particular were kept may be

rooted both in the special conditions for hospitalizing lunatic patients as well as thefact that psychiatric knowledge was based principally on these observations. Already

by the 1830s, the patient records of the psychiatric department were stored separatelywhich showed the importance of these records for administrative purposes and

having them at hand for re-admissions. For instance, they were lent to authoritiesand external offices such as forensic experts or health insurance companies which

meant that the content had to be in a form that was comprehensible to lay-persons.At the end of the journal there had to be a short summary. In case of death, the acting

doctor had to fill in the diagnostic findings of the autopsy according to theexamination protocol.

However, the nearly 50,000 patient record files archived today in the Berlin

institute were not passed down from the archives of the Charite registry. They owed


their existence to the introduction of a new model of archiving: the double filingsystem. With this term we want to describe the opening of a second folder – copied

primarily for medical reasons and archived in the clinic itself.The beginning of the double filing system cannot be dated exactly. We assume that

the patient files were copied regularly since 1876 because only few have survived frombefore. In the clinic vocabulary, the copied records were called ‘Bureau-Journale’

which means that the clinicians sent true copies back to the admission office whilekeeping the original. Often the administration didn’t get an exact copy but an

extended excerpt–and we would like to know what the physicians left out.Copying patient records was not unusual in late nineteenth century hospitals. Emil

Kraepelin seemed to be the first who introduced duplicating patient files because the

files accompanied the patient when (s)he was transferred to the regional asylum.19

For Kraepelin, the copied files represented the ‘raw material’ for an elaborated system

of analyzing the basic symptoms of mental disorders on which he based theclassification of psychiatric diseases. As a consequence, it is reasonable to guess that

the Berlin clinicians also duplicated the patient record for scientific purposes;however, they copied the files given to the administration (the so called ‘Bureau-

Journale’) while they kept the original files in the clinic. The few remaining Bureau-Journale can clearly be identified as such copies were written by the interns as well as

by patients after recovering. The Bureau-Journale were written throughout in thesame handwriting in contrast to the different styles in the clinical files written byseveral different doctors in the form of ongoing entries.

As a result patient records in the Charite hospital, now called ‘clinical records’ havebeen continuously developed by the administrative routine of record filing. The act of

duplicating these records—and with the originals kept by the clinicians—highlightedthe growing scientific role of patient recordkeeping. These different purposes also

changed the meaning of the files. They were now regarded increasingly as thedocument of the doctor-patient-relationship which bestowed a personal status of

strict confidentiality to them. The original notes were also held to be the intellectualproperty of the involved physician that meant that the patient records were notallowed, under any circumstance, to be handed out to external persons. The records

became a kind of capital, reflected in the economic-sounding jargon that argued forthe resources of the scientific enterprise: ‘this is a principle for the body of our

scientific work. Like a merchant does not allow an insight into his main book, butkeeps the account for his mental orientation and business disposition, so it is

impossible that we lend the journals, in which our mental material lies.’20

This systematic filing of clinical records points to the role of collections for

producing scientific knowledge; a theme which the historiography of science andmedicine has paid a lot of attention to in recent years.21 Collecting therefore represents

the necessary constituent in the practice of medical sciences: no laboratory existswithout a laboratory journal, no research trip is done without travel journal, and noclinical trials carried out without protocols for bedside observation.22 Recording data,

collecting hasty notes, transferring, copying, and editing entries can be considered as


the basic operation of scientific practice. In this paper technology, the modern patientrecord plays an important role as seen in the efforts for collecting and filing these

materials prior to the publication of ‘results’. Patient records are definitely not anycollection of final results. They constitute, however, the specific form of collecting

information and materials which may be potentially relevant and important. Thisepistemological status of potentiality characterizes the institution of the archive.

Creating medical records should also be regarded as an archiving process in itselfin which the fleeting observations, ephemeral impressions, and vague associations

were jotted down on paper. This procedure seems to be so self-evident that medicaland reference books very seldom discuss even today how to do it. Only historicaltreatises give an impression that the emergence of recordkeeping was reflected in or

had consequences for medical thinking. In 1899, the German psychiatrist RobertSommer published an essay about the psychopathological method in which he

mourned that ‘pure observation was immediately deformed through plenty ofconclusions, emphases, and omissions, so something else was noted as it happened in

nature, i.e. in the patient [. . . .]. The initial idea of the diagnosis often guides furtherobservations by neglecting all that does not fit with preconceived belief. Doing so

results in hospital records that show the patient as the typical melancholic, while amore accurate examination would have demonstrated a paralysis’.23 In principle, the

psychiatric doctor reserved the clinical description for ‘the eldest one of allpsychopathological methods’. However, ‘the traditional way of writing a psychiatricpatient history was recording the casual, accidental, and subjective observations

blurred in ideas in the course of the ward rounds and the reports of the personal’.This was the reason why Sommer recommended a more objectified inquiry for

describing psychopathological phenomena.24

Complaining about insufficient records threw light on the rising role of psychiatric

recording for this young discipline. Noting so much information as precisely aspossible was the recurring refrain as the decisive criteria for science. The traditional

forms and schemes often left the physician alone in recording impartial anddisinterested observations. In the end, however, the objective of keeping eachobservation that might be relevant prompted an open process without end.

Transferring the recording from analog to digital storage does not solve the principalproblem of losing potential facts. The traditional patient record seemed to be useless.

But the principle of recording and collecting the phenomena at the bedside is stillpresent in psychiatry and can be seen in each revision of the Diagnostic and Statistical

Manual of Mental Disorders. The media may have changed but the epistemic functionof recordkeeping remains: the classical patient history is being increasingly replaced

by recording devices like the AMDP schema25 (Working Group for the methodicdocumentation in psychiatry (Arbeitsgemeinschaft fur Methodik und Dokumenta-

tion in der Psychiatrie, AMDP) and other formalized procedures for recording,objectifying, and rating psychopathological phenomena.

At the Charite hospital in Berlin, the system of double filing ended in 1919. With

the treaty of Versailles, military subordination was cancelled due to the


demilitarization of the German Empire, and the clinicians kept all records. Theyappointed typists for writing the notes and reports from the clinical wards. This

change, however, is another story which would lead us deeply into the moderndivision of labour for recent practices of hospital filing.

Notes

[1] Risse, 1986.[2] Craig, 1989–1990; Craig, 1990; Howell, 1995; Timmermans und Berg, 2003, chapter 2.[3] The records of the Hotel Dieu in Paris go back to the 11th century (Riche. 2000).[4] Hahner-Rombach, 1995; Beddies und Dorries, 1999; Nolte, 2003; Meier et al., 2007; Kloppel,

2009; Goldberg, 1999, for psychiatric hospitals; Ikpektechi, 1983, for surgery; Roth, 1935, forinternal medicine and Ritzmann, 2008, for pediatrics.

[5] The project is funded by the German Funding Organisation (DFG) to whom we are grateful.We would also like to thank J. Andrew Mendelsohn for help and collaboration.

[6] Hess and Mendelsohn, 2010.[7] The training function of the Charite was established as an element of a broader policy

developing a non-academic, practical-oriented education in medicine and surgery for thePrussian military in the early 18th century.

[8] Instruction fur den Pensionar-Chyrurgo von 1737, x10 (Neuhaus, 1971: 227).[9] Instruction fur den Pensionar-Chyrurgo von 1737, Universitatsarchiv der Humboldt-

Universitat zu Berlin, (in the UAHUB at note 19), Akten der Charite-Direktion 1725–1945,No. 180, 99r.

[10] The leading staff of the hospital administration was recruited from veteran sergeants andtherefore trained in basic bureaucratic techniques.

[11] Instruction fur die Pensionair-Chyrurgi im Maison de Charite von 1791, x2 (Neuhaus, 1971:237).

[12] Hess, 2010.[13] For venereal diseases, more specialized schemas were used to document the standardized

treatment.[14] Dohrmann, 2011.[15] In the 1830s, the Charite Administration counted six leading physicians, 12 military surgeons

and 35 interns from the Pepiniere. The staff included 22 officers (registrars, recordingsecretaries, economy officers, chief nurses, clerks, apothecaries, priests). The service personnelcomprised the chief cook, the chief wash woman, two orderlies, five porters, one bread-cutter,one beer tapper, two night-watchmen, four lamp clerks, one delivery boy, one bath attendant,one corpse watcher, three guards, two apothecary clerks, one corpse-washer, three bathwater-carriers, one cutter, four corpse and firewood-carriers, six servants (one for the militaryofficers, two for the interns, two kitchenmaids, one kitchen servant, eight maidservants, ninewashmaids, two stable boys, four housemaids).

[16] Kittler, 1985.[17] Niehaus and Schmidt-Hannisa, 2005.[18] Pomata, 2005.[19] Engstrom, 2005.[20] UAHUB, Akten der Charite-Direktion 1725–1945, No 1238, 116. ‘Das ist ein fundamentaler

Satz fur den Aufbau unserer wissenschaftlichen Arbeit. Wie ein Kaufmann sich nicht seinHauptbuch von anderen einsehen lasst, sondern das zu seiner geistigen Orientierung undgeschaftlichen Disposition fuhrt, so ist es auch unmoglich, dass wir die Blatter, in denen unsergeistiges Material liegt, verborgen.’


[21] Kohler, 2007; te Heesen and Spary, 2001.[22] See here the special issue of the Intellectual History Review 20 (2010), especially Blair, 2010.[23] Sommer, 1899: 154.[24] Dohrmann, 2011.[25] Mezzich, 2002; Haug und Stieglitz, 1997.

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Hess, Volker/Sophie Ledebur: Taking and Keeping. A note on the emergence and function of hospital...

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