New York Hospital Patient Medical Records

New York Hospital was chartered in 1771 by King George III of England. The hospital was erected along the west side of Broadway in Lower Manhattan, New York. A fire and the Revolutionary War delayed the opening of New York Hospital until 1791. From its founding the hospital received both pay patients and charity patients. Payment was for the patient’s cost of boarding at the hospital, though the medical treatment was free. Anyone was eligible to be admitted as a charity patient at the Visiting Committee’s discretion.

New York Hospital had medical and surgical divisions. The hospital clinical staff involved in creating patient medical records for the divisions included an attending physician and surgeon, house physicians and surgeons, and senior and junior assistants, sometimes referred to as senior and junior walkers, which was a reference to them accompanying the house physicians and surgeons during their daily patient visits.

The earliest mention of medical record keeping appears in the 1811 bylaws of New York Hospital, which noted that it was the responsibility of the senior assistants, under the direction of the house physicians and surgeons, to keep a register of all cases. The bylaws specified the information to be entered, which included the name, age, and occupation of each patient, the probable cause and history of disease, the remedies used before and after admission, the name of the attending physician or surgeon, their daily reports on the case, the termination of the disease due to recovery, relief, or death, and other circumstances that provide additional details on the nature of the disease and record of the operation (in the case of the surgical divisions.)

Until 1897, the attending physician or surgeon identified the cases they thought were worthy of preservation, and those patient medical records were saved and bound together in a casebook. With the introduction of admission and history numbers in January 1898, the hospital began keeping all patient medical records, foregoing the earlier selection process. The casebooks containing bound patient medical records were submitted monthly to the Visiting Committee for review and then secured in the hospital’s library. The safekeeping of the casebooks later fell under the purview of the hospital’s superintendent after the library closed in 1898.

Requirements for accessing patient medical records became more stringent over time. In the early 1800s they were available to friends of the patients in addition to the Board of Governors, physicians, surgeons, and students attending the hospital. However, by the turn of the 20th century, with the exception of the Board of Governors, physicians, and surgeons, permission for accessing the patient medical records required a written request to the Visiting Committee or the superintendent. The Executive Committee rules in 1898 note that requests from attorneys or corporate representatives with ongoing lawsuits involving a former patient would not be allowed to access the patient medical records without explicit consent from the patient.

New York Hospital closed its original location in February 1870 and opened a second, larger location on March 17, 1877 between West 15th and 16th Streets near Fifth Avenue in New York, NY. In its new location, the New York Hospital again had both a Medical Division and Surgical Division. In the first year the building opened, the inpatient department had 165 beds and treated 1,493 patients and the outpatient department treated 1,694 patients. By 1931, New York Hospital admitted 6,482 patients a year, in addition to seeing 12,884 outpatients. The increase in patients in the second location of the New York Hospital was reflected by an increase in the volume of patient medical records generated during this time.

New York Hospital closed its doors on their West 15th Street location and opened their third location, a joint medical center with Cornell University Medical College, at 525 East 68th Street in September 1932. Although patient medical records are actively created in the third location of the New York Hospital, these records are not preserved in the Medical Center Archives.

BIBLIOGRAPHY:

Secondary sources:

Bellevue Hospital Committee on Clinical Records. The Bellevue Hospital Nomenclature of Diseases and Conditions with Rules for Recording and Filing of Histories. New York, NY: Clarence S. Nathan, Inc.: 1922. https://babel.hathitrust.org/cgi/pt?id=mdp.39015072193033&view=1up&seq=3

Pool, Eugene H. and McGowan, Frank J. Surgery at the New York Hospital One Hundred Years Ago. New York, NY: Paul B. Hoeber, Inc., 1929.

Primary sources:

New York Hospital By-Laws and Rules, 1811, 1838, and 1845. (Medical Center Archives of NewYork-Presbyterian/Weill Cornell Medicine, New York, NY).

New York Hospital Rules Enacted by the Executive Committee. 1886, 1898, and 1923. (Medical Center Archives of NewYork-Presbyterian/Weill Cornell Medicine, New York, NY).

The Society of the New York Hospital Annual Report for the year 1914. (Medical Center Archives of NewYork-Presbyterian/Weill Cornell Medicine, New York, NY).