History of Disease

History of Disease (historia morbi), also called the 'sorrow sheet', is a record in a specific form of information about a patient in a medical institution. The history of disease is an official document certifying the patient's presence in the medical institution, their state of health upon admission, during their stay in the medical institution, and upon discharge, the treatment performed, surgical operations carried out, etc., and in case of death—the time of its occurrence, the phenomena accompanying it, as well as brief autopsy data (patho-anatomical diagnosis). The history of disease represents valuable material for scientific and statistical work and research. It also often serves as material for judicial and forensic-medical investigation. Until 1929, in the RSFSR there was no single form of the history of disease, obligatory for all medical institutions. Such a single 'state' form of the history of disease did not exist in the pre-revolutionary period either. The absence of generally binding rules concerning the filling out and storage of the history of disease caused extreme diversity and disorder in the organization of this matter. The history of disease was compiled in different localities and separate medical institutions in various forms and sizes. In hospital archives, the history of disease often represented a chaotic mass of carelessly written, torn, and differently formatted material, little or completely unsuitable for medical-statistical and scientific-clinical study. Meanwhile, a number of major scientific works written on the basis of the study of archives of the history of disease of various clinical institutions are known. The history of disease, containing records on the state of the patient, on the results of laboratory and clinical research, forms and methods of medical influence and intervention, thus reflects the entire course of the disease process and provides material for judgment and evaluation of the doctor's activity and the organization of the work of the medical institution. Proper maintenance of the history of disease has great educational and methodological significance for the doctor. The history of disease gives the attending physician the opportunity to reproduce all the preceding course of the disease, to control his actions, to verify the applied methods and means of treatment; at the same time, it accustoms the doctor to systematic observation, develops critical thinking, and strengthens his sense of responsibility. For a therapeutic and preventive institution, the history of disease is material on the basis of which it controls the work of each individual doctor and studies the morbidity of the population served. Proper maintenance of the history of disease is of especially great importance in the conditions of Soviet health care, which has as its main task the improvement of the labor and life of the population based on properly organized accounting of morbidity and the study of its causes. The history of disease, like a personal sanitary journal, is a document reflecting not only the individual but also the social etiology and pathology of each individual disease. According to the data of the history of disease, in many cases it is possible to establish a connection of the disease with social and professional conditions and harmful factors, and consequently to outline a path for corresponding health-improving measures. Therefore, from the point of view of the tasks and interests of Soviet health care, it is especially necessary that the history of disease be written with due completeness and clarity and contain the necessary information concerning social and professional etiology, pathology, and diagnosis of the disease. In order to introduce the necessary order into the matter of compiling the history of disease and ensuring its proper storage and proper use, the Narkomzdrav RSFSR developed in 1927 a model form of the history of disease for all medical institutions; in 1929, the 'Instructions on filling out the history of disease' and 'Instructions on the order of storage of histories of disease' were published. Maintenance of the history of disease according to these established forms and rules is obligatory for all therapeutic, therapeutic-preventive, and scientific-clinical institutions—state, departmental, public, and private; the established Narkomzdrav form of the history of disease can be supplemented by local health authorities and medical institutions. The established Narkomzdrav model form of the history of disease consists of three parts: a) general registration information about the patient (name of the patient, his age, family and social status, profession, etc.), b) data on the disease—anamnesis, subjective indications and complaints of the patient, data of objective examination (clinical, laboratory, and patho-anatomical) and c) data on the course of the disease and treatment (sequential record of clinical observations, results of analyses, applied methods of treatment, surgical operations, etc.). The 'Anamnesis and subjective complaints of the patient' contain the following information: the onset of the disease and its first manifestations, subsequent changes in the course of the disease until the moment of the patient's admission to the medical institution; conditions of development and life in childhood, diseases of close relatives, sexual life and its anomalies, intoxications, alcoholism and other drug addictions. During objective examination of patients, brief information characterizing the general state of health and the state of individual organs and systems (growth, build, nutrition, skin, subcutaneous tissue, mucous membranes, bone and muscular systems, organs of respiration, circulation and digestion, genitourinary organs, nervous system and mental sphere) must be recorded. At the same time, the results of laboratory, X-ray, and other special studies are also recorded. In the history of disease of nervous and mental patients, data concerning the heredity of the patient, his constitution, previously transferred infections and physical injuries, acute and chronic intoxications, as well as conditions of labor and life, way of life, etc., are recorded in more detail. In the part of objective examination of nervous and mental patients, special attention is paid to the state of the main reflexes, psychomotor, emotional, and intellectual spheres, level of development, orientation in time and surroundings, mood, excitability, obsessional and delusional states, peculiarities of speech and writing. The history of disease, upon completion of its maintenance, must be signed by the doctor who conducted the treatment of the patient, as well as by the head of the department and the medical institution. Data entered into the history of disease by a consulting doctor must be signed by all doctors participating in the consultation. Upon discharge or death of the patient, the history of disease is handed over to the institution's office or another place of storage of the history of disease established by the internal order rules of the medical institution. The order of further storage of the history of disease and their use for scientific and scientific-statistical purposes is determined by the following rules: the history of disease is stored in therapeutic-preventive institutions for the period of storage established by law for institutions with completed paperwork materials. Upon expiration of this storage period, the history of disease is transferred to the archive of the corresponding regional (krai) health department for temporary use by the latter for a period of 15 years. Transfer of the history of disease is made in complete annual sets according to inventories with obligatory leaving in the transferring therapeutic-preventive institution duplicates of these inventories. In order to facilitate the use of the history of disease, for reference purposes each annual set of the history of disease must have an alphabetical list of patients indicating in it the number of the history of disease for each patient. The history of disease, transferred in the manner indicated above for temporary use by health authorities, are stored by them in chronological order, separately for each year, in manila folders (approximately one hundred copies in each folder), with indication on the folders of the name of the therapeutic-preventive institution, the year, and the extreme numbers of the history of disease located in that folder. During the entire period of the history of disease's stay in therapeutic-preventive institutions and in the archive part of local health authorities, the latter have the right to organize the use of the history of disease for scientific-research purposes in a special room for studies; in special cases—these materials may be issued under their responsibility for the same purposes to medical scientific organizations and individual persons. Upon expiration of the period of use of the history of disease, they are handed over by health departments to the corresponding local (krai or regional) archival bureau separately for each therapeutic-preventive institution. In the depositories of local authorities of the Central Archive, the history of disease is not included in the composition of the archival funds of the corresponding therapeutic-preventive institutions, but are stored separately from the named funds, for each therapeutic-preventive institution separately, with distribution by years and separate institutions in order of numbers. The Central Archive of the RSFSR has the right of control over the storage of the history of disease by health authorities and supervision of the fulfillment of established rules. Destruction of the history of disease, received into the jurisdiction of the Central Archive, may be carried out by the latter only by agreement with the corresponding Health authorities.