The patient’s chart should contain name, sex, age, colour, address, occupation, social status (married, single, or widowed), and a brief history concerning the onset and progress of his disease. These charts may be as simple or as elaborate as one desires. Herewith is submitted a specimen chart, such as are used in Baltimore; they are not perfect, nor the acme of all that is or might be desirable in a record of this kind, but they have proved simple and fairly satisfactory. There is much left out which with advantage might have been added, but in this connection it is well to remember that an elaborate and exhaustive history, one demanding dozens of intimate details, is apt to alarm the patient excessively. To collect exhaustive statistics would be valuable for the sociologist, but to do so at the expense of the patients’ confidence and trust would be to defeat the object of the work itself.
Patient’s Chart. Cardboard, five by eight inches
Reverse side of Patient’s Chart, showing spaces for recording visits. The Second Chart Sheets are similar to this, but alike on both sides
The reverse side of this chart contains spaces in which each visit may be recorded. Sometimes these charts are kept up for months and years, and it is therefore necessary to have what are called second sheets—alike on both sides, and resembling the reverse side of the first sheet, which contains the patient’s history. These sheets are fastened together, and the chart of a chronic case may thus record hundreds of visits. Each nurse is responsible for keeping up the charts of all patients under her supervision. The notes should be carefully recorded at the end of each day’s work, for it is bad policy to let this charting accumulate for even two or three days. The entries should be brief and concise, and should describe the patient’s condition, or the work done for him.
Each nurse should have a filing box or drawer in which to keep these charts; they should be arranged in alphabetical order, and kept at the central office, where the superintendent may have ready access to them. These charts are the property of the association, and under no circumstances are to be removed from the central office. The nurse may make her entries upon them either at the end of the day’s work, or before she goes on duty the next morning.
Closing the Chart. Patients are removed from the visiting list when they die, or when they are discharged. They are discharged only for one of three reasons—either they leave the city, or they move and their address is lost, or they prove not to be tuberculous. When a patient dies or is discharged, a suitable entry is made on his chart, which is then turned in to the superintendent of nurses, or to whomever is responsible for the records. If there is only one nurse, it is of course her duty to file these closed histories. These records should be rich mines of sociological information, and should contain valuable material for those who have access to them, such as municipal authorities, physicians, and social workers. Except for the access allowed to these, the files should be confidential.
The Card Index. All offices should contain a card index, giving the name and address of each patient under supervision. Change of address should always be noted, since it is only by means of this card index that the particular chart desired can be referred to. For example: the card index contains the names of some 3000 cases, all under supervision, and each one having its own chart. The charts themselves, however, are distributed among the filing boxes of several nurses. If particulars are wanted concerning John Doe, it would be necessary to turn first to the card index, find his address and the district in which he lives, and then turn to the filing box of that district and take out the chart. If it were not for the card index, it would be necessary to search through all the filing boxes before finding the desired chart.
