Committed to the Sane Asylum: Narratives on Mental Wellness and Healing

Appendix II: Clinical Records and Glossary

Rosemary Introduction to Susan’s Mental Health Records In Ontario, the physical clinical record is the property of the health professional or institution where it was prepared. By law, any patient is entitled to a copy of his or her own clinical record. The clinical records for Susan and her uncle Leo Marrin Regan were obtained by the usual means—with a written request and the payment of a nominal fee. The records included here are complete with the exception of a few items—namely, Susan’s photograph, the names of hospital staff, and personal information about Susan’s siblings. A glossary at the end of this appendix (p. 286) defines technical terms that are mentioned in the clinical records and later conversations and includes some apparently ordinary words such as orientation when these words have a specific technical meaning in mental health practice. Clinical Records of Leo Marrin Regan Susan’s brother requested the clinical records for their uncle,Leo Marrin Regan, who lived his entire adult life in psychiatric hospitals. The letter from the Kingston Psychiatric Hospital (pp. 241–42) is likely a summary of clinical records for Mr. Regan. This uncle’s situation was not known to Susan or her family until 1995, many years after her own hospital admission. 237 II Appendix Clinical Records Glossary Clinical Records of Susan Schellenberg Susan requested her own clinical records; her account of receiving the records is included in chapter 5. The nurses’ notes, which would have provided information about Susan’s activities and status on a daily basis, are unfortunately not available. Dr. Mary Seeman (see chapter 5) pointed out that nursing notes in that period were stored separately and retained for a shorter time than the rest of the clinical record. Initial Admission Forms The first pages were likely completed by clerical staff in the admitting department on 2 September 1969, the date of Susan’s hospital admission; they provide basic identifying information—name, address, telephone number, and next of kin. Next is a form required by law in circumstances where the person is admitted as an“involuntary”patient, which was the case for Susan’s admission . This form was completed by a physician, probably in the emergency department, and outlines the reasons for Susan’s involuntary admission. Involuntary status means that the person does not consent freely but is required to come to and remain in hospital because a designated official—usually a physician—believes it necessary because the person suffers from a mental disorder such that there is risk of serious, immediate danger to either him- or herself or to others. Once the necessary legal form is completed, the police have the authority to search for the person and bring him or her to the hospital , and the hospital has the authority to physically prevent the person from leaving until the certificate expires or is lifted by the treating physician. The procedures for certifying a person as an involuntary patient are outlined specifically in law, and are different now from what they were in 1969 when Susan was admitted. After a person is admitted, he or she is designated a patient. Nursing and medical staff on the hospital ward do further evaluation. In Susan’s case, the ward admission record was probably completed by a nurse to provide information about Susan’s physical condition, status, and possessions at the time of admission.A medical examination is a routine aspect of admission for psychiatric patients and is intended to ensure that any physical health problems are identified and treated. The physical examination form for Susan was completed by a physician, and provides the doctor’s evaluation of her medical health status on admission. Next come laboratory reports on blood and urine tests done just after admission, including a routine test for syphilis (VDRL). 238 Appendix II Clinical Notes and Reports The clinical record is a series of notes made by staff psychiatrists concerning the patient’s symptoms, clinical impressions of difficulties, and diagnoses. Information in the notes would have come from interviews with Susan or discussions with nurses or other staff. The social record is based on an interview with Susan’s husband. The psychological examination consisted of the psychologist having a series of interviews with Susan and administering several personality tests. The conference report is based on the conclusions reached in a meeting of all members of the professional team...