|F«3* A FORM OFRECCRI o" JC K 1 K U jl J:l /u> r Aa IyiJd ! I il ! i ii !; 1 fir1 M-r im, n!i ill iiHi.i i!;! ! i'i:! illH-ri.i I I 11 II i !i: lip 'Hi! !i|: ' ■■! W 322 F233f 1921 28310290R NLM 05115^7 7 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. Section------------------- No. 113, W.D.S.G.O. NLM051154677 V f~rTk i r>4 moo \SUKol;QN GF.N^AL'S / ■v. OFfiCF. ^- '" A FORM OF RECORD FOR HOSPITAL SOCIAL WORK A FORM OF RECORD FOR HOSPITAL SOCIAL WORK INCLUDING SUGGESTIONS ON ORGANIZATION BY GERTRUDE L. FARMER in Director, Department op Social Work op the Boston City Hospital Boston, Massachusetts ':■ LIBRARY J PHILADELPHIA. LONDON & MONTREAL J. B. LIPPINCOTT COMPANY L tftO COPYRIGHT, 1921, BY J. B. LIPPINCOTT COMPANY w PRINTED BY J. B. LIPPINCOTT COMPANY AT THE WASHINGTON SQUARE PRESS PHILADELPHIA, U. S. A. 0EC27h2i/O ©C1.A653265 FOREWORD This book on record organizing in Hospital Social Service is welcome because its author's scheme for case histories lays special stress on the thinking that must lie behind thorough social case work. Emphasis in such work quite naturally tends to fall upon doing rather than upon thinking. The situations which daily confront the worker are appealing and urgent, and the action they call for (at least part of it) may seem of an ob- vious sort. The prompt securing of convalescent care, for instance, is not infrequently a laborious and difficult task, a drain upon patience and tact, but is not one that demands what we ordinarily term reflective thought. Convalescent care, how- ever, may be only incidental to a need for a readjustment of the patient in family life or in working conditions, such as can neither be recognized nor adequately met without careful analysis of the elements entering into the individual situation. It is this sort of analysis which the author aims to stimulate by the "thought-provoking" catagories of her social ser- vice card. An important part of the plan here advocated is the regu- lar and skilled supervision she recommends for the apprentice in case work. Such supervision is much more than an over- sight of record-keeping alone; it really amounts to a contin- uous training in the essentials of case work itself. In this training the record is treated for the important thing it is: namely, the worker's thinking objectified. This conception of the social case history, or record, has brought a growing con- viction to my own mind that in these written documents, which the worker must produce to sustain her reflective grasp of her problems as they develop, lies an opportunity for discipline in social thinking of which we have only begun to take advantage. Ada E. Sheffield, Director, Boston Bureau of Illegitimacy. 5 INTRODUCTION The record which is here suggested is for a specialized form of social work,* primarily adapted for the use of hospitals dealing with large numbers of both ward and out-patients. The following are the chief purposes I had in view in writing on this subject: I. A realization that all hospital social record writing is more or less of a bugbear, both from the point of view of the case worker and the executive, and a desire to do what I can to help in this difficult phase of our work. II. A belief that I have evolved a scheme of recording which has already appealed to many both as more practical, more economical, and more efficient for hospital social work than those ordinarily in use, together with the conviction that an important step toward standardization of hospital social work throughout the country would be the adoption of a more or less uniform system of case recording, and the gathering of statistical data. III. A desire to get my material together in such concise form as would serve to make it easier to respond to the requests for information about our records which come to us from time to time from hospitals all over the country. The repeated copying of long lists of detailed instructions to send to indi- viduals would entail too much clerical work, merely sending samples of the record cards does not answer the purpose at all. Furthermore, it is practically impossible to really demon- strate the record scheme, which I have in mind, without rather full instructions and illustrations from the actual case material. IV. A hope that my record material may prove of use in the training of students for hospital social work. Judging from an experience gained during many years of social work in large hospitals, and an association with many hospital social * Since this manuscript was written, the Russell Sage. Foundation has published Mrs. Sheffield's Social Case History. There are points of similarity, both in type and method, between the two, and I would sug- gest that any hospital social worker who is considering a new form of record should read the two in conjunction. 7 8 INTRODUCTION workers, a fair majority of whom at least have had some experience in one or other of the accredited schools of social work, there is at present a lack of adequate training for the student, not only in the make-up of the hospital social record itself, but also in the arrangement and selection of record material, and in the implications of the different types of social case work which will be met with in the course of a hospital social worker's actual intake. It seems to me that in training students for hospital social work, the chief function of which, many of us believe, is social case work with indiv- ual patients, more stress should be laid upon as important a part of the technique as record writing. The Author. CONTENTS Chapter page I. Considerations Influencing the Choice of a Record Form............................... 11 II. The Short Service Record..................... 20 III. The 5x8 Record. (Figures 4 and 5).............. 26 IV. The Extension Folder......................... 34 V. Some Further Use of the Extension Record System...................................... 44 VI. Illustrative Records.......................... 53 A FORM OF RECORD FOR HOSPITAL SOCIAL WORK CHAPTER I considerations influencing the choice op a record form Any social worker in a general hospital, dealing with all types of cases, who will look back over a year's case work, will find, I believe, that the ones which required long, intensive recording, while much in her consciousness, were in the minor- ity, and stand out like mountain peaks, in an otherwise rather flat landscape. The type of record to be used by any social agency must necessarily originate from the demands of the general intake of the particular agency. Hence a social department within a hospital must determine the nature of its intake as the first step in choosing the form of record to be used. In a department of social work connected with a large, general hospital, three types of needs may be recognized: I. The so-called "slight" or "short" service rendered to a considerable number of patients, without much social investigation. II. Intensive social case work, indicating such follow-up service as would complete the medical treatment, plus the adjusting of the social problem, rendered to a comparatively smaller number of patients. III. Intensive social case work, indicating medical follow-up work, plus long-continued social activity in the effort to adjust complex social situations, rendered to comparitively few patients. Hence an adequate hospital social record system, it seems to me, should lend itself flexibly to these three types of intake. Many of the problems met with by social workers within a hospital are closely concerned with the hospital administra- tion, and its medical service to the patients. Many of these situations have to be dealt with promptly, with little or no time for deliberation, or painstaking social investigation. Common sense and good judgment alike, call upon the hospital social worker to relax her professional technique. Although often conscious that further social investigation might dis- close social disabilities, she has to ask herself, "What, even then, would have to be the action taken?" Prolonged social 11 12 RECORD FOR HOSPITAL SOCIAL WORK questioning and investigation which, from the nature of the case, could not probably result in proportionate action, is to be avoided, whether within or without a hospital, as leading to what someone has aptly called '' a sterilized bureaucracy.'' There were many considerations which led me during my first year at the Boston City Hospital, to delay starting a regular record system, and to try and devise a form of record- ing which would, I hoped, more nearly meet our needs than the chronological type commonly in use, the scheme of which was borrowed in the beginning from older " lay " social agencies, many of them differing in some essential peculiarities of organi- zation and intake from the social department within a hospital; many of them also having themselves already shown signs of a decided tendency to develop entirely new methods of record- ing. Among the considerations I had in mind as tending both to delay and conservatism in the choice of a record system were the following: I. The fact that each hospital, like each community, while possessing things in common with other similar institutions, has essential differences both in organization and personnel, peculiar to itself. Moreover, the social side of all medical work, including the training of medical students, is still in its pioneer stage, so that those interested in introducing this new element into hospital organization have had to win their way by slow degrees, and to spend considerable time and effort in merely gaining a foothold. Up to the present most depart- ments of hospital social work have been "tacked on" to insti- tutions many of which had previously been in existence a long time, and were themselves suffering from lack of space and means to expand in what, many consider more legitimate direc- tions for medical institutions. II. The realization of the often limited size of the paid staff in other hospitals where social work had been established, and the amount of work which each worker could be called upon to handle, compared with the numbers of hospital patients that were at least referred to such a department, and who were probably much in need of the type of service a social worker could render, in order to make their medical treatment effective. These needs have to do with ensuing the return of certain patients to the clinics through actual contact with the homes; assisting the hospital to better fulfil its function to RECORD FOR HOSPITAL SOCIAL WORK 13 the community through closer cooperation with outside medi- cal and social agencies, both public and private. III. A realization that record keeping of any kind is time and space consuming, and expensive. I had never known a department of hospital social work which even pretended to have enough clerical service, office room, or equipment. I knew, moreover, that this was a part of the work which did not make the same appeal as that part which dealt more directly with the patients, so that it seemed obvious that it would always be more difficult to get the necessary support to pay for a liberal amount of such equipment. Whether deliberately planning a new form of record or not up to that time in starting a department there was, I believed, a distinct advantage, in being able to delay the organ- ization of the whole clerical side of the work, including office plant, until it had been possible to become somewhat familiar with the peculiarities of the new field. Delay in clerical organization has the added advantage in that it helps to postpone the undertaking of much case work in the pioneer days. There is always a temptation in all social work, where the sympathetic appeal is so strong, to plunge in before taking soundings. Much, however, cannot be expected of a depart- ment which lacks clerical workers, typewriters, filing cabi- nets, and all the paraphernalia. It is essential, of course, from the start both to demonstrate the work and to familiarize oneself with one's new field. To do this it is advisable from time to time, both to collect, classify and publish certain statistical data, and to undertake the after-care of a certain number of carefully selected cases. During our first year at the hospital the only social record we kept was a 3 x 5-inch card, with carefully selected topical head- ings, the whole written in longhand. (See Figs. 1 and 2.) These served our purpose well. Later they were numbered, indexed, and formed the nucleus of our record system. Some of them were later expanded through our extension folder scheme. All letters and other data having been preserved with some such end in view. In planning the form of record to use I had in mind: Conciseness. Elasticity. Adaptability. 14 RECORD FOR HOSPITAL SOCIAL WORK I wanted to save the time, (and money) of the department, as well as office space, and, while recording sufficiently for our needs, to save the time and effort of the case workers. I felt that while the bulk of our records must, and should, be brief, that we needed a form which would allow of indefinite expan- sion, in order to be able to record our more intensive case work, and to allow for teaching material. C^arsMilrerT lr. July'OS. "BT*. DosW Case 56 /i,T>»T V + - Fir*r Visit. ftbiVfc. family ; Fa.Tercy^O)l>.l?€.I. oce.TeaWis'er • wa'05. 3»*hcrs. JVwi (r'0« die (r.'oT di'ej *f Hwos. "Weak Heart' C.i.o[X ? No. Fig. 1.—Front side. AN INDIVIDUAL TYPE OF RECORD The fact that several persons have advocated the use of the family as opposed to the individual form of record for hospital social work has been due, I think, to the same influence as led to the use of the chronological as opposed to the sum- mary method of recording, namely social work tradition. Sickness has always seemed to me to be the only logical starting point for hospital social case work; sickness ex- pressed in terms of an individual human being. The type I selected, therefore, was an individual, not a family record. This has always seemed to me the logical form to be used in a hospital, where the unit handled is a patient with a disease, or diseases. The patient has a background of family, home, school, work, community, apart from which he cannot be con- RECORD FOR HOSPITAL SOCIAL WORK 15 sidered, without a consideration of which no social diagnosis can be made, or social treatment prescribed. In relation to the patient's home and work conditions it is, of course, natural that a socially minded person, trying to help someone, should have his attention called to any other member of the family, who appears to need assistance. If this member of the family is contributing to the care and support of the patient, it is again natural that such care and support should be strength- ened and made more effective. In the case of an infectious T?eSou.fces: ScVioal, A wos Welter QSecov»J Grade.) Family PhysicidYi-. 3r. Jo-nes, "lei. Allstan 10 2. NeiejhtoTv. (Vs. 3e^ne"tt> Tel. <. q^ Plan: io . May %. l?efy. I.D.W.fl.,awd teacher, (*\isa SnT.th. JtaVte U. S'<%.t\*f} Sent 1* Coy* vales. Home. OuU 'Ik. Cl©tV>ar "t«jlciT»a p>T. 7o country for vacation, coviJi+i<»v» «vnpp#r«j. L«it »*» car^e r«l»tives. Fig. 2.—Reverse side. condition, whether moral or physical contagion, care of other exposed persons is also socially logical. A CHRONOLOGICAL FORM OF RECORD The form of recording decided upon was the summary, as opposed to the chronological type. Here again the form which has been in common use in hospital social departments was borrowed from outside social agencies most of them having their approach to the situation from a different angle from the hospital social worker. The summary form of record appeals to many of us who have read large numbers of social case histories, and have found it difficult to obtain from them concise case pictures, with definite information both as to the nature of the social 16 RECORD FOR HOSPITAL SOCIAL WORK problem involved, what action was contemplated, and what really accomplished, to say nothing of summary analyses of the whole problem. "Miles of records that no one ever reads." "It was impossible to tell whether anything was really accomplished on the case, there was so much detailed information as to steps taken," are among the complaints often heard. It seemed to me that a summary form of record would not only save time, space, and expense, but, if arranged with selective topical headings, would challenge the workers to SHORT SERVICE RECORD Name Date Address Age S. M. W. Identification House No. Service Admtd. C. E. of I. Disc. Medical Diagnosis 0. P. D. No. " '' " Dept, Remarks Fig. 3.—Short service record. attempt the presentation of complete pictures of their case work in small compass. During the now nearly five years that we have used the record, only minor changes and additions have been made, and the following is now the form we are using (June, 1921) : I. A Short Service Record. This consists of one 3x5 card, typewritten on one side, with a few printed topical head- ings. Filed by name, without an index card. (Diagram No. 3.) II. An Index Card, 3x5, with name, address, case num- ber, date referred, medical department or service of the hos- pital where the patient was being treated when we first made Fig. 4. Case No. Depar tment of Medical-Social OF THE Boston City Hospital Work Date Worker Name C. W. Age Wks. mos Date of Birth yrs. House -No. Address Place of. " How long in Boston Ward Service Medical Diagnosis - - " U.S. S. M. W. Nationality Citizen Admitted Discharged Referred by Settlement 0. P. Dept Why Religion Church Financial Condition " " No. First visit. Previous Medical Care Resources Occupat ion Industry Social Problem Social Background to Medical Condition Plan Previously Registered C. E. of I? 18 RECORD FOR HOSPITAL SOCIAL WORK RECORD FOR HOSPITAL SOCIAL WORK 19 a record of his case, the name of the worker who made the social record, the names of the patients' nearest relatives (for speedy identification). Filed by name, and used in connection with the 5 x 8 record. (Figures Nos. 9, 12, 15, 18 ; pages 51, 55, 58.) III. One 5x8 Record Card for more intensive recording, with printed topical headings. Used on both sides. Filed by number. (Figs. 4 and 5.) IV. An Extension Folder Record, attached to the 5x8 Record Card. This consists of an 8y2 x 14-inch sheet,* type- written on both sides, without printed, but with suggested, topical headings. There can be as many of the 8y2 x 14 sheets as desired. They are filed in a manila folder, wihch bears the same number as the 5x8 Record Card of which it is the extension record. The 5x8 card is red starred (*** ) to indicate when it carries this extension record. * The reason for our having the Extension Folder sheets 8y3xl4 was because that is the size of the medical history sheet already in use in the hospital, and it had been suggested to me that we might later have the social summary bound up with the medical record. I see no other ad- vantage in selecting this sized sheet. CHAPTER II THE SHORT SERVICE RECORD As indicated above, this provides a suitable form for a larger number of patients, involving a minimum of recording, thus helping to indicate the volume of work carried, and secur- ing more complete monthly statistics. So far it has seemed feasible to file these unnumbered rec- ords by name in a separate drawer, and without an additional index card. This method, while it has saved filing space and clerical work, has certain disadvantages, in that it gives any- one trying to identify a case from the files an additional place to look, and leaves nothing in the file when the record is with- drawn, or even, as will happen, is temporarily mislaid. As an additional means of keeping track of our records we have kept monthly lists showing type of record, whether Short Service or 5x8, and giving the name of the patient, date of month and year, and the name of the case worker. These lists are useful, not only for identifying individual records, but as furnishing quick information as to monthly intake from the beginning of the work. These are some of the more superficial types of work for which the 3x5 record card can be used to advantage: I. For recording service to other members of the family when work with the original patient has been noted on a 5x8 record. (Figs. 21, 22, 23,* in connection with Case 5497, 5x8 card and folder.) II. For the speedy recording of information, which would otherwise be lost, as a longer record might not at first seem indicated, but which would be of value if the case became socially more intensive. In this case the information con- tained on the short service card is incorporated into a 5 x 8 record, the 3x5 card destroyed, and the case noted in the month's statistic's as "new," thus preserving a correct yearly total of patients. For the purpose of careful checking the fact that a Short Service has been turned into a 5 x 8 Record is noted both on the index card, the 5x8 Record under '' Re- marks,'' and on the checking list referred to above which the *See pages 74 and 75. 20 RECORD FOR HOSPITAL SOCIAL WORK 21 stenographer keeps. This having to decide upon the choice of record forms, and to realize that a case has become socially more intensive helps to make a worker more analytical of her intake. III. For recording that nursing care has been provided in the home, through referring to district, or other forms of nursing service. Our part in this should include not only getting the nurse to go into the home and transmitting to her the hospital physician's directions, but also to see to it that short service recordMIss Grant. Name Santinilli, Frances Hat.Italian DatJuly 2/20 Address 19 Broad St., South Boston Age65 /-/m \/ Identification Dau. Mrs. Julia Presby, add. 51 House No. ChOat e St., Maiden . Service Admtd C.E.6f I.Family Welfare Society #26341 Disc. Medical Diagnosis Fractured Clavicle. O P d No27931 " '« " Dept. Surg. Remarks Ref .by Dr.R. for home supervision as pt.'a condi- tion does not allow her to come back and forth to hospital alone. Dau.who came to clinic with pt: "Pt. living with in- valid hue., income $13. mo. fr. O.of P. Dau.unable to sup- plement sufficiently." Conf.with F.W.S.: They will take up social problem. Dist .Dr. * Diat.Nurse sent in. July 31/20, Transf. to P.W.S. (fol.clinically). Fig. 6.—Form of record showing that nursing care has been provided. " the patient is sent back to the clinic from time to time until discharged O.K. by the doctor. (See Fig. 6.) IV. For recording our visits to the homes to find out why patients have not returned to the hospital for treatment, when instructed to do so by the doctors, and sometimes why they have not responded to written directions to return. This con- stitutes what is known as typical medical-follow-up work as it is understood by the hospital staff. The term has been too loosely used to cover other forms of social work in hospitals, which cannot be so described.* V. For recording the transfer to other institutions of cer- tain chronically sick and disabled patients. (See Fig. 7.) * Many of these follow-up home visits are made where there is no form of social record. 22 RECORD FOR HOSPITAL1SOCIAL WORK VI. For recording the keeping track of within the hospital, and interpreting to outside agencies the need involved in the after-care of certain patients, the major part of the outside social care of whom is to be borne by the cooperating agencies. These constitute the so-called "steering" cases. While a department of hospital social work should in no wise be looked upon as a general Bureau of Information, as has too often been the case, many hospital superintendents, in constant receipt of communications from social agencies regarding the after- care of patients will be anxious to avail themselves of the ser- SHORT SERVICE RECORD Miss M Kame Isaacs, Aaron Sat .English-Hebrew Date June 20/19. Address 211 Field Street, Roxbury Age 68 p.M.\f. Identification fife, Annie,66. Dau.Mrs .Swan, House No. 259S32 add.above,hus.waiter,5 chn. Son,Aaron,cut- Service I Med, ter, clothing store, Revere Beach. Admtd.Apr.l/19 C E. of I. h0 . Disc. June 30/19 Medical Diagnosis Myocarditis . Hemiplegia. O. P D. No. " '« " Dept. Remarks Ref .by Dr.A.to get history from rels. because pt. cannot give intelligent information. Vis.address given by pt. dau's.home,clean,6 rooms,1st floor. Dau: "Parents have lived with her 10 yra; 2 roomers,bro.helping a little, but income small. Pt.not worked 10 yra.had shock then,at inter- vals since. Cannot do more- for him & could not support in priv. hosp. June 30/20. Transf. Long Island Hospital. Fig. 7.—Form for recording transfer to other institutions. vices of a group of hospital workers whose function largely consists in readjusting the patients to the community. It is important to remember in this connection that the majority of hospital executives, while perfectly willing to refer such matters to hospital social workers, prefer to have all such communications go through the Executive Office, in this way the authority ultimately responsible for what is done inside the hospital is kept informed. (Fig. 8.) Careful judgment has been used in the selection of the topical headings for the 3x5 card, and advantage taken of every hair's breadth of space. Elite type is used on all our typewriting machines. This saves quite a little room, and RECORD FOR HOSPITAL SOCIAL WORK 23 looks neat. It would not be possible to get our arrangement of material on our cards if we used larger type. Besides the identifying and statistical information on this card under the topical heading of "Remarks," the workers are instructed to include: Who referred and why; statement of patient and, possibly, of nearest relative and friends; reports of agencies, if any; and what was done as expressed in statistical "Action Taken." The small amount of space necessitates the elimination of short service recoro Hiss Grant. Name Murphy, Anna lat.American Date Jan. 16/20 Address 8 Fay Street, Roxbufy Age 17 S.^i.ff. identification Fa. James, 47,b.Boston,d.Ho .Anna, House No. asthmatic, at tends clinic B.Cons .H.O.P.D.BrosService James, 18,machinist asst.Edward, 14; Sis. Aflm,d Winifred, 11,at school. ' Admtd- u,a 1T;Tes.0.of P.,Mother's Aid Dept.'17. Disc. Medical Diagnosui -Malnutrition.■ O.P.D.No. 46171 " '' " Dept. Med. RcmarksRef .by Dr.H."Sent in by O.of P.to see if able to work;should not do so;20 lbs.underweight;should attend Nu- trition Clinic." Mo:»Pt.delicate; is in 3rd yr.High Sch., now a ? of cutting off aid and putting to work.Bro.earns $17.50 wk. Ho.'s Aid $5." Letter to O.of P.giving Dr.'s ad- vice.Home visit:5 rooms,clean;pt .sleeps alone,windows open. Fa.died of phthisis. Feb/20.Adm.to Nutrition Clinic. Fol. Fig. 8.—Form for recording the keeping track of patient in hospital. every unessential word. "Boiling down" to a strong extract is the order of the day. It is good practice in what it is unnecessary to say. It is possible to attain quite a pro- ficiency, and it is to be observed that the habit of eliminative writing can help in "giving cases" at Conference, tersely and to the point. Those of us who have "listened in" at many case conferences will appreciate this point. As mentioned below we do not file our records with those of the previous months until after the monthly statistics are complete, usually about the end of the first week of the month following. Before completing our statistical count either my assistant or I go over each short service card carefully with a view to advising the case worker whether to turn some into a 24 RECORD FOR HOSPITAL SOCIAL WORK 5x8 record at once, or to eliminate them altogether. The following "Rules for Writing Short Service Record" are furnished to each case worker. While some of the material here given is a repetition of parts of my text, I thought that it might be of interest to give these directions in the form in which we use them at present. RULES FOR THE USE OF THE SHORT SERVICE RECORD " These include those cases where the need of definite social action appears to exclude the necessity of outside in- vestigation, etc. A social record can be made later and the short service card destroyed, if the developments of the case indicate it. When this is done the case is then noted under '' new.'' Out-patients who are only kept track of in the clinic, and where no outside agency is called upon, should not be noted statistically at all, except on the hospital medical record. Such clinical-follow-up can be taken for granted." '' Short Service cases may include the following: I. A visit to the home to see that the patient returns to the clinic. Such a visit may readily disclose the need for further social action when a different form of record may be decided upon if desired." "II. Referring a patient immediately to such societies or institutions as give definite medical or nursing care, as the Baby Hygiene Association, Dental Clinics, etc. In the case of most visiting nurse associations care is needed to see that the patient comes back to the Out-patient Department, unless it has been decided to call in a district or private physician, be- cause a district nurse has a rule which requires that she should have medical supervision. When these cases become socially inactive it is better to leave them in their own care or in that of relatives, rather than to transfer them to a more or less medical agency like a dental clinic." '' III. Exceptional cases not classified. Such call Tor indi- vidual judgment." '' Great care should be exercised in deciding whether in any particular case to select a short service instead of a 5 x 8 rec- ord. The choice of record form will have an influence in determining the kind of work undertaken. If unable to de- cide this question for themselves workers should seek advice. The wrong or overuse of a short service record tends to pre- RECORD FOR HOSPITAL SOCIAL WORK 25 elude the doing of really good case work as such cannot be recorded on this form. Social statistics based on too super- ficial social recording will fail to show what has really been accomplished. Action on a case where a 5 x 8 record is used may readily include any of the above, and only where a small amount of social action is to be taken can the case be called one of short service." 1' Remarks:'' Under this should be included: 1. A concise statement why referred and by whom. 2. Reports of any societies knowing patient. When more than one, well to give under one heading as: "The above societies report:'' 3. Brief note on patient's statement as: "Has been in lodgings up to admission, not worked six months, no savings.'' 4. Summary of what action taken as: " Home visit. Con- ditions fair. Family income $15 per week. Patient has slept in kitchen but mother can arrange to have a single room. Re- ferred to—Evening Clinic." "If short service cards are used only as indicated their use will not only be limited, but they will comparatively sel- dom require to be carried over from month to month. Care should be taken that material to be entered should be as com- plete as possible when first handed to the stenographers, and that all inactive cases are so noted at the end of each month. Cases where the social action is finished, as far as we are con- cerned, but who may continue to be kept track of in the clinic should be considered as socially inactive and so noted under one or other of our statistical headings." CHAPTER III THE 5x8 RECORD. (FIGURES 4 AND 5) This with the index card constitutes our principal social record form on which the greater bulk of our social work has been recorded. The adjustment of some of the simpler, more acute, social situations may here be adequately recorded. The distinction implied when this, instead of the shorter form, is used, serves to clarify, and bring out the prospectus of the work as a whole to the case workers. While many of the topical headings are the same, of course, as those used on the face sheet of other agencies, such as relig- ion, occupation, nationality, care has been used in the selec- tion of some of the others, and an effort made to choose those which would, if properly used, be most thought provoking, compel social investigation, and present a case picture in a very small compass. Care has also been taken in arranging these headings according to the case workers' usual sequence of investigation, with due regard to saving the time of the typist, and for quick reference. For example, as will be seen by reference to Fig. 4, all the data relating to medical record numbers, ward, Service, admission, discharge, are grouped together, as is the data giving the patient's civil condition. While we have never changed the size of the card from the original 5 x 8-inch, we have somewhat shifted, and changed the topical headings, until now we seem to have got them to where they are the most convenient as well as the most descriptive. To write certain parts of this record successfully it is necessary to bear in mind that the case material cannot be dictated offhand, but has to be sorted out and arranged under the selected headings, which have been provided for this pur- pose. To decide under what heading any particular item of information belongs, and to put it there not only results in a useful, quickly readable record, but trains the case worker in that rarest quality of a good case worker, selective judgment. Below I have given a copy of the "Directions for Writing the 5x8 Record and the Folder" which is given to each case worker, and although it involves some repetition, I should like 26 RECORD FOR HOSPITAL SOCIAL WORK 27 to point out here in addition what seems to me the most sug- gestive parts of this 5x8 card. "Why": Implying one place for stating the concrete reasons which led the doctor, or others, to refer the case. If referred by a physician giving briefly, but informingly, the medical opinion, including prognosis, and such recommenda- tions for further medical and social treatment as the referrer sees to be indicated. Social investigation will sometimes dis- close that the social part of the prescription is wide of the mark, but it is of value as serving to show what is in the back of the mind of the referrer, and as at least suggesting the first course of social action. While seemingly not requiring a great deal of imagination to write successful, adequate '' whys,'' I have found that with some workers to do so is rather the exception than the rule. Many will write: '' For after-care on discharge,'' which is to say the least undescriptive, and can be taken for granted. Under Directions How to Use the 5x8 Record, given below, I have tried to indicate further what points our workers are asked to have in mind in composing a good "why." While the chief value of this heading is in conjunction with certain other parts of the record, as the medical diagnosis, the Social Problem and Social Background, the following may be of interest as showing what I consider fairly '' good Whys.'' They are from actual records. Referred by a hospital interne: "Patient is single; was delivered of twins, premature, the second a breach presenta- tion ; patient on danger list. She gives history of another child now a year old. Babies should be kept to breast if possible. Will you look after her ?'' Referred by visiting surgeon: "Patient is up against it; seems to have no responsible relatives; in desperation broke into a store. Surgical condition chronic, damage is done, but needs out-patient care. Should have sitting down job." Referred by an executive officer: "Patient's condition chronic; she is the mother of twelve children. Can she be provided for at home, or is she a case for an almshouse hospital?" '' Social Problem '': This should be recorded as soon as a 5x8 record has been decided upon. It challenges the worker to ask what is the nature of the social situation in hand. It 28 RECORD FOR HOSPITAL SOCIAL WORK serves as a test whether the case is one demanding a 5x8 record at all, and frequently brings out the implications in- volved in some of the medical diagnoses, and as determining what plans to form, as well as what preliminary action to take. For example, if the medical diagnosis is phthisis, with positive sputum, the Social Problem as presented to the case worker might readily be Protection of the Community, and the con- sequent Plan might include: " To arrange for sanatorium care, or its equivalent, and look up other members of the family." If the medical diagnosis includes some form of chronic heart disease the Social Problem might be Physical Handicap, and the Plan include: " To keep the patient under regular medical supervision, look into his previous home and work conditions, and try to obtain suitable employment." If the form of heart disease is acute not chronic, the patient a child, and inquiry shows that the home conditions are bad, while this patient like the other will probably be physically handicapped, the Social Problem in this case might be: "A Neglected Child," and the immediate Plan: "To obtain admission to a Heart Hospital, keep under medical and social supervision on discharge, and look into home conditions." Sometimes, on the other hand, it is obvious that the medical diagnosis has no connection with, and throw no light on the social problem which has come to the knowledge of the case worker through some other channel. For example, abnormal home conditions will usually have no connection with a diagnosis of fractured bone, although the same patient was the victim of both. Case workers are provided with a suggestive list of '' Social Prob- lems," and are encouraged to make efforts to add to it from time to time. (See list on page 29.) "Plan": This forces the worker's mind to focus on a definite course of action. Having to record that one is con- templating a concrete plan of action as soon as the nature of the social problem is realized serves to guide the case worker through the preliminaries of case work and to decide upon what social treatment is to be given. The difference between contemplated and definite action as expressed in terms of something actually accomplished, cannot be too firmly insisted upon in relation to hospital social case work as expressed in '' Plan'' and '' Action Taken.'' Under Directions for Writing the 5x8 Record I have further expanded this idea. RECORD EOR HOSPITAL SOCIAL WORK 29 "Resources": When correlated to "Plan" causes a fore- handed analysis of the essential steps of treatment, both in utilizing previously known resources, and in finding new ones. Case workers cannot too clearly define in their own minds the difference between available and theoretical resources. Suggestive List Home and Family Problems Family Discord Marital Discord Bad Home Conditions Abnormal Home Conditions Lack of Family Coordination Poor Home Environment Neglected Home Broken Home Desertion Maternal Incompetence Paternal Irresponsibility Maternal Irresponsibility Paternal Neglect Incompetent Home Making Child Welfare Problems Neglected Child Stubborn Child Physically Handicapped Child Orphan Half Orphan Illegitimate Child Motherless Child Juvenile Delinquent Educational Neglect Bad Heredity Feeble-Minded Child Adolescent Instability of Social Problems. Occupational Problems Unsuitable Employment Industrial Disablement Industrially Handicapped Need of Occupational Guidance Need of Change of Occupation Problems of the Individual Drug Addiction Intemperance Inebriety Sex Delinquency Immorality Insanity Feeblemindedness Protection of the Individual Protection of the Community Unmarried Maternity Unmarried Pregnancy Friendlessness Unemployability A drifter A Social Derelict. Maladjustment to Environment Prostitution Suicidal Ideas Need of Expert Medical Care Inadequate Income Irregular Income Unemployment Problems of Poverty Maladjustment to Environment Chronic Poverty and Physical Disablement "Social Background": To be written when the case is more or less inactive, compels a review of results of investi- gation and endeavors to show what the environment of the patient has been up to the date when the medical diagnosis was made, and the social problem stated. It may serve to indicate the causative factors in the situation. It is an at- tempt, in a very few words, at a summary analysis of the patient's past environment of home, school, work, etc., up to the date of admission, an effort to trace the relation of the 30 RECORD FOR HOSPITAL SOCIAL WORK present distress to some element in the past environment of the patient, and of his reaction to the same. Such attempts at analysis, which in the nature of the case have often to be based on superficial and insufficient knowledge, while of dis- tinct value in training the worker to analyze and sum up her work, and as serving as recorded guides to the future social diagnosis and treatment of the case, must be used with caution, and with due acknowledgement of the many chances of error. If all hospital social workers could have training in the mental side of their case work it would be of benefit when they come to attempt these summary analyses. This was the worker's idea of the Social Background of the patient noted above as referred to us by the visiting surgeon: "An orphan for several years; educated in a parochial grammar school. A broken home, absence of training along industrial lines, and the further handicap of a progressive bone disease, may have been causative factors in the patient's be- coming a member of a "gang," and being brought to the attention of a police court. In addition, the patient is some- what hospitalized.'' I think the determining what is the real nature of the "Social Problem," expressed in one or two words, as distinct from the "Plan," and the writing of the "Social Back- ground, '' are the most thought-provoking, as well as the most difficult parts of my 5x8 record card. To write certain parts of the record successfully it is neces- sary to bear in mind that the case material in certain parts, cannot be dictated off hand but has to be sorted out, and carefully arranged under the selective headings, which have been provided for the purpose. To find under what heading any particular item belongs, and to put it there, not only results in a useful, quickly readable record, but trains the case worker in that rarest quality of a good worker, selective judg- ment. I have found that it is quite difficult to train even quite experienced case workers in this selective process. In reading their records one constantly comes across informa- tion out of place. The old chronological, rambling type of record encouraged this. I don't believe, moreover, that in training students sufficient emphasis has been placed on this need of selective judgment, both in the type of record used and the arrangement of the material. RECORD FOR HOSPITAL SOCIAL WORK 31 In addition to the directions for writing this form of record given below, it is perhaps only necessary to add here something on the headings "Action Taken" and "Remarks." "Action Taken" : Implies only real activity, as expressed in tangible, as opposed to contemplated or pending action. Under this heading, under Remarks, and in certain parts of the folder record we make some use of dates in order to show the sequence of our case work. The entries are, however, sum- marized, under Action Taken no effort is made to record each visit, telephone call or letter as these are considered simply methods of work, and as showing how the worker spent her time. Two visits may be too many, twenty too few; it all depends upon the purpose and accomplishment. Instances of entries might be: "Date of month and year, June 1, 1921. Home visits. Interviewed mother. Letter to School Princi- pal." As is noted below, "Action Taken" should be ex- plained and justified under "Remarks." '' Remarks ?': Under this should be brought together in logical sequence any significant information which cannot be arranged under any of the other headings, together with some analysis of the steps in what social treatment is given as indicated under "Action Taken," correlated by similarity of dates. For example, if an important home visit is noted under "Action Taken," together with an interview with a relative, a brief report of the conditions observed, and significant in- formation gathered should appear under "Remarks." An explanation of the final disposition of the case as indicated statistically under "Action Taken" should also be here given. It the responsibility is to be intrusted to others an effort should be made to show why this action was justified. For in- stance, if a dependent is to be "Left in care of relatives," the worker should justify this action by showing that they were capable and willing to assume such responsibility. It is essential under "Remarks" that all unnecessary and qualifying words be eliminated, and the worker should bear in mind to avoid the expression of personal opinion, either her own or that of others unless it can be shown that it has important bearing on the case. Letters : A summary of any important correspondence re- garding a case should be entered under "Remarks" on the 5x8 record and then either destroyed or kept in a letter file 32 RECORD FOR HOSPITAL SOCIAL WORK marked "Correspondence concerning patients." The same is true concerning the Short Service Record. I believe that only such correspondence need be kept as is of real value for future reference and for the protection of the Department and the workers, such as showing agreements with other agen- cies or individuals. In the case of letters from patients which serve as valuable, although unconscious, self-revelations, a few selected specimens are all that it is necessary, to retain. In cases where there is an extension folder any correspondence can, of course, be retained, although here again it is often preferable to enter a short summary under date and then destroy. There is no doubt that in reading a record the major- ity of us refrain as far as possible from reading the corre- spondence attached. It is usually rather boresome. The following suggestions indicating when to select a 5 x 8 instead of a Short Service Record were lately handed me by one of our case workers (Miss Anne L. Estabrook). As they may prove suggestive, I will add them. factors leading to the selection of the 5x8 record I. Cases where the situation must be studied from many angles, even if we do not personally do much, before we reach a final decision. For example, in the case of an adult with a chronic disease, this may take much thought, and the weighing of different factors, which must be shown in the record to jus- tify our action, as where the father of a family is transferred to an almshouse hospital instead of to the care of his children. Another case of transfer to an almshouse might be adequately recorded on a Short Service Record. II. Cases where we call in, and refer the case to a social agency after we have collected social evidence. For instance, a cardiac man needing light work might be referred to a Men's Welfare Department on a Short Service Record if this were a social need entailed by a medical situation alone and did not re- quire social analysis to any extent on our part. But an epileptic not requiring institutional care, with an irresponsible family, would have to be recorded on a 5 x 8 even if we also referred him to a Men's Welfare Department but investigated his his- tory, heredity, and family relationships first, as we prob- ably would. RECORD FOR HOSPITAL SOCIAL WORK 33 III. Cases where we become involved socially as well as medically. IV. Cases which are apt to return to the hospital, on which we have detailed evidence which may later make social action possible on a later admission which should not be lost even if we decide not to give social treatment at present, and where the detailed evidence is too long to put on a Short Service Record, as well as too valuable to be much abbreviated. V. Cases where we formulate a definite social problem and suggest a plan, even if we are not the agency carrying it out. VI. Briefly, cases where there is more than a question of medical steering and hospital routine should be recorded on a 5x8 card. It is not so much definite social action as analysis and formulation of a problem that make this form of record essential. There are some cases of medical steering, however, which, though uncomplicated by a social situation, are so long, and so dependent on a social worker, that they require the 5x8 record. The problem in these cases might be the need of expert medical care in a person who, except for this purely medical need, would not require any assistance at all from a department of social work. CHAPTER IV THE EXTENSION FOLDER This is, I think, the unique feature of this record scheme. It has been planned for when, in spite of concise analysis, the complexities of the social problems involved overburden the 5x8 card. There is no limit to the space allowed in the folder, although it is a summary record, and here, as in other parts of the record, prolixity is discouraged. So far the only topical headings used have been those noted below. It would be pos- sible, however, to work out different ones to suit certain types of cases where there is an active need of research material, for example, as in unmarried maternity, industrial accident cases, etc., and we have planned to do this. So far the three selected, however, have, as a matter of practical utility, ap- peared to serve our needs, and have allowed for great elasticity in recording. Under "Directions for the Use of the 5x8 Record and the Folder" I have included most of the following information about this part of the record. "How the Case Came to Us." This includes the psy- chology of our approach to the patient, plus the recommenda- tions given by the Dr., or other referring agent. It is the same as the "Why" of the 5x8 card, but can be at greater length if desired. "Sources of Information." Often beginning with a brief word picture, in parenthesis, of how the patient impresses the worker at the first interviews, including physical appearance. Usually followed by the patient's own story or statement, and trying to weave all the obtainable interpretations of the patient's character, past environment, and previous activities, as viewed by others interested in the situation, into a readable form, having in mind to try to give free development to the psychological insights, so necessary in establishing the realiza- tion of the patient's needs, and as a basis for effective social treatment. '' Social Treatment Given. '' The material under this head- ing is a summing up of all the social treatment of the case, including the friendly approach to the patient, and the means 34 RECORD FOR HOSPITAL SOCIAL WORK 35 whereby it may have been considered to have been accom- plished, as well as the more concrete action. Significant crises in the treatment, a summarizing of the results of the previous investigation, are corner stones for such recording, and de- mand continually the imaginative, analytical, and constructive powers of the worker if the record is to be completed with conciseness and perspective. While dates can be referred to for the sake of clearness, there should usually be no attempt at any definite dating of the paragraphs until the preliminary phases of the treatment are recorded, and the complete summary of the case work pre- sented, then, if the case continues active, or is reinstated, it can be brought up to date occasionally by means of summary entries under the month and year, or oftener if desired. One of the difficulties in writing the folder has been to get the workers to train themselves to distinguish between action which is taken in order to get information which will form the basis of social treatment, and action which is taken in order to give the various forms of social treatment; the former belong- ing under "Sources of Information," and the latter under "Social Treatment Given." The two courses of action often run along together, and no hard and fast line can be drawn between them. If, however, the worker does not clearly analyze her work, and distinguish between them in her own mind, she will, probably, not succeed in writing a clear sum- mary. The worker must ask herself: Is this information on which I may hope to base my social treatment of the case, or is it information which may simply enlarge my knowledge of the patient's past life, or is it information which should be set aside altogether as not informing? For instance, if one of the chief purposes in our social treatment of a case is to reconcile a girl to her relatives and rehabilitate her in the home, a visit to that home might readily be recorded both under "Sources of Information" and under "Social Treat- ment Given." Again in questioning a patient in order to elicit general information for the record the worker, during the course of these interviews, may win the confidence of her client in which case again she has certainly taken an important step towards the social treatment of the patient. Care in paragraphing, underlining certain headings in red ink, the introduction of a few direct quotations in the exact 3G RECORD FOR HOSPITAL SOCIAL WORK words of the informant, showing interpretation and character- ization of the situation lend vividness, and help to make a readable record. It is necessary to remember that red ink and direct quotation lose vividness if used to excess. The giving of a copy of the following instructions on the use of the 5x8 record and the folder to a case worker pre- supposes some knowledge and experience in case work tech- nique. Hitherto we have found it necessary to supplement with a good deal of interpretive verbal instruction. directions how to use the 5x8 record card and the folder Name.—Give in full, surname first. Address.—Means place of residence and the one where the patient was living at date of admission to the hospital, or when first referred to the Out-patient Department. This is not always the one on the admission slip or the out-patient record. When address not a permanent one, it is well to put (temporary) after it. Medical Diagnosis.—Do not use abbreviations. Medical Diagnoses are not capitalized except at the beginning of a sentence. Give clinical symptoms and comments as hemor- rhage, positive sputum, acute, slight, also results of tests, X-rays, etc., in parenthesis or under the "Why." When later diagnoses obtained or changes made in a previous one give date with additional diagnosis. In the case of subsequent treatment in another hospital, give the name of hospital, date when reported, before diagnosis, as: Jan. 22, '15, Psychopathic Hospital, Dementia Praecox. Referred By.—Designate by name and office as Dr. Wm. Smith (House Physician), (Junior Externe), (Visiting Phy- sician), (Supt.), (Asst. Supt.), (Asst. Executive), Miss Jones (Nurse), Mr. Holt (Medical Supervisor). Why?—State in unhackneyed words the referrer's reason for asking medical-social assistance. When the referrer is a physician he should give information on the medical condition, also the prognosis and suggestions for after-care. Sum up the gist of what he says. Try and bring out his ideas of the func- tions of hospital social work. This is the place on the record where you should give the details on the medical situation. Previous Medical Care.—Give names of any other hos- pitals, sanatoria, convalescent homes, etc., patient may have RECORD FOR HOSPITAL SOCIAL WORK 37 received treatment in, with date and diagnosis, as Boston Dis- pensary, 1911-1915, Cardio-renal. Name and address of any private physician who treated patient prior to admission, with diagnosis. When a private physician has only been called in at the last moment to get the patient admitted to the hos- pital, his name would probably not be of any real value. In the case of an out-patient, state whether previously treated in other departments or in the House and vice versa, with, if possible, dates, hospital numbers, and diagnoses. Occupation.—In case of a child attending school, the occu- pation is scholar, add number of grade. Give any other occupation as chore boy at home, errand or newsboy. In case of an adult, give the actual work performed as, general domes- tic, cook, waitress, cutter, heel polisher, spinner, mail carrier, housewife. Shops, factories, vessels, homes, hotels are in the nature of industries, and have innumerable occupations con- nected with them. Do not confuse the two. Be explicit and detailed. Industry.—Means the nature of, as grammar school, pri- vate family, restaurant, shoe factory, cotton mill, U. S. Mail Service, hotel. Do not give the name of any particular school or plant. When necessary note that under resources, or remarks. Social Problem.—Try to express in two or three words the nature of the outstanding social need which leads you to feel that social interference is necessary. Like physicians, hospital social workers should accustom themselves to rapid (social) diagnoses of a situation, and try and focus on the nature of the social defect before giving treatment. Do not confuse the present social problem on a case with the analysis of the past history which you note under Social Background. For convenience we have started a list of possible "social problems." Workers should add to this from time to time, as better ones occur to them in the course of their work and study. Plan.—Indicate the medical-social treatment which you hope to secure for the patient. It may be formulated during the first interview. It can be added to, as when patients are put on waiting lists pending admissions to institutions; it is well to add the date when this is done. Do not confuse plan with method of work.. "Home and school visit," "Confer 38 RECORD FOR HOSPITAL SOCIAL WORK with teacher," are methods, not plans. "To provide chronic institutional care," "To obtain past history, give oversight and guidance, and provide convalescent care" are plans. Previously Registered Bureau for Confidential Exchange of Information.—Answer yes or no. Give names of agencies, with dates. If patient known only through another member of family answer yes, and put after name of agency the name of relative in brackets as, Yes, ------Provident Association 1919 (Bro. Edward). C. W.—(Colored, or white.) Cross off the negative one. Age and Date of Birth.—Weeks and months are important in case of infants or young children. Note both by year and months in such cases, infants note also weeks, and give year and month of birth. In case of adults the age in years will, in most cases, be sufficient, and is usually all that can be obtained. Place of Birth.—Give name of city and town. When born in U. S. outside of state or in a foreign country, give name and state, when possible, as Middleton, Conn., or foreign country. How Long in Boston and U. S.?—Give "life" or number of weeks, months, or years. This question suggests the patient's available resources and helps to determine settlement. As absence for certain lengths of time nullify settlement, dates within which the patient has resided in . . . should be noted here, or under remarks when the answer to the question is vitally important. Nationality.—In case of minors this includes the fathers and is hyphenated. If the father is a Jew born in Russia and the patient was born in U. S., the latter is a Hebrew- American, not Russian-American. In order to note that the child is an American it is necessary to know that the father was born here. Place of birth and nationality are not the same. A man born of English parents in Japan is an English- man and not a Japanese. Citizen.—Answer yes or no. All people born in U. S. are such. Adults can acquire citizenship by naturalization, minors can acquire it through parents. S. M. W.—Indicate whether single, married, or widowed by drawing a line through two. Settlement.—If the patient is known to be settled, give the name of the town as Boston. When the patient has no settle- ment in Massachusetts write "no." Since 1916 settlements in y RECORD FOR HOSPITAL SOCIAL WORK 39 Massachusetts may be acquired by certain periods of residence in a town. Laws vary in different states. Settlements relate to municipalities and not to states or countries. They are important in determining who shall '' pay the bill,'' and what institutions, etc., the patient can claim as a right. Religion.—Give the name of the faith as Methodist, Roman Catholic, Hebrew. Church.—Means the particular edifice which the patient has attended, and should be expressed by a name, as Tremont Temple; Gate of Heaven; The Synagogue. When the patient does not attend at all, note "none," or "no special." The group of numbers and dates, department and service seem too obvious to need elaboration. When admitted and discharged more than once in the course of the case work give the various dates. When the patient dies in the hospital, put "dead" after the discharge date, and add it at the top of the record in red. First Visit.—Means date of first visit to the 0. P. D. and sometimes serves to show that hospital social work may help to bring about more thorough treatment through making avail- able to the patient the different departments of the hospital, and seeing that he gets there. Financial Condition and Liabilities.—This includes wages, insurance, whether sick benefits, gifts from friends or em- ployer, savings. In case of minor note wages of father and other members of family, rent, debts. In all cases where patient is a member of a family note the wages of other mem- bers of the family if they contribute to the support of the patient. As: wages $15 per month (not worked for three months) no savings. Carmen's Union, sick benefit $3 per week for ten weeks (has received five weeks). Sister Jane's wages $5 per week. Rent $10 month (two months in arrears). Put wages of members of family here, and not under Relatives. Active Resources.—In all cases give name and nature of connection with patient as Hyde School, Miss Smith (teacher), C. A. Soc. (Agent Mr. Jones). Do not put names of relatives whose connection with and support of patient is obvious, as in the case of parents of a child. In case of brothers, aunts, etc., where the obligation to help cannot be taken for granted, give name, etc., as Mrs. Annie Smith (mat-aunt), 72 Common St., United Fruit Co. (employer) Mrs, Margaret O'Brien, 93 40 RECORD FOR HOSPITAL SOCIAL WORK Fay St., (friend and former landlady). Resources may in- clude schools, churches, relatives, employers, but should indi- cate contributing sources, not merely acquaintances or persons known to the patient. Social Background for Medical Condition.—This is a summary analysis of the patient's previous social environ- ment, including home, school, and industrial conditions. The.se may be shown to have had some bearing on the present medical diagnosis. It follows investigation, includes abstracts from other parts of the record, and should not be attempted until the case is somewhat inactive, or at least fairly familiar to the worker. Avoid personal opinion, and details as to future treatment. Try for a brief word picture in abstract terms. Our 5x8 record card, with elite type, allows for not more than from 60 to 70 words under this heading. Experience shows this to be sufficient when well arranged. Relatives.—Give immediate family; in case of a minor put father, mother, brothers, and sisters in order named; also in the case of a single adult. When married give husband or wife first, then children, brothers, sisters, Names of parents are not of consequence in case of married or old people. In case of children grandparents are often of consequence as they can be called upon to support. Uncles, aunts, cousins and relatives through marriage should be noted when the relation- ship appears of consequence to the patient. Write each rela- tive in the following way: Nature of relationship to patient, name in full with maiden name of a wife or mother, age, place of birth, address; when same as that of patient note "as above," occupation. Add any particular comment or illu- minating data which refers directly to the relative. In case of brother, sister, aunt, etc., note civil condition after age as (m), (w), (s). Action Taken.—This is not a day-by-day narrative, but a statement of concrete actions including visit, or visits, to home, school, social agency, conferences with relatives, etc., when latter not visited, in which case a conference can be taken for granted. Referring or transferring to a society or institution should include the actual thing done and not a contemplated action. Referring to an institution should also mean ad- mitted ; to any agency that the case is accepted and action of some kind taken; when an agency is consulted about a patient RECORD FOR HOSPITAL SOCIAL WORK 41 already known to them call it "conferred with." Add dates to each subsequent action. In case of out-patient the social record may be noted as inactive and the patient left in care of relatives, etc., while still followed in the clinic, this should be noted in parentheses. The worker should have other means of recording the medical follow-up work as a note book, calen- dar, card catalogue, visible index, etc. Should a subsequent medical examination disclose a need for renewed social action the case should be reinstated and date noted. All workers must use the same statistical nomenclature. It is important to enter statistical data at the end of each month, especially when the cases become inactive, thus enabling office workers to answer inquiries from other agencies as to our activity or in- activity on a case. Reinstatements of inactive cases should also be noted for the same reason. Another reason is to convey information to another worker who may later handle the case. Remarks.—As the space is very limited, care should be taken to put data, whenever possible, under other heading. Notes on later X-ray, and other diagnoses made at this or other hospitals, data on relatives, and resources belong else- where. Important data which cannot be classified elsewhere, reports from societies, statements from the patient or relatives, when they throw light on the situation belong here. A long report can sometimes be condensed to a few words, and lose nothing in the process. Reports from various societies can be summarized under: "Above societies report." The use of a colon may eliminate the word report. The worker should no more omit important data than put in unimportant details or opinions. It is well to know why a case has become inactive. For example, when Action Taken is "Left in care of rela- tives, '' a report under remarks showing the nature of the home and school environment may justify the step. Do not report initial interviews, etc., so fully that you have no room for your social treatment of the case. Folders.—Workers should remember that a folder record has been provided. It is to be used in connection with, and as an extension of the 5x8 record card, and to carry the same number. The record card is red starred (***) to indicate the presence of a folder in the files. It is to be used where the social chronicity of the case calls for, and justifies the use of 42 RECORD FOR HOSPITAL SOCIAL WORK more space. It can be added to the record card at subsequent date. It is obvious that certain of our cases cannot be effec- tively recorded, and much valuable data would have to be omitted unless we make use of a longer record than the 5x8 card. We have used the following written headings: How the Case Came to Us.—This is an enlargement of "Why Referred" on the 5 x 8 card. Sources of Information.—This includes the results of all investigation preliminary to social treatment. The patient's own story, gathered at initial and subsequent interviews, but written consecutively. Information from relatives, friends, landladies, employers, etc. Reports from other social agen- cies and institutions. Social Treatment Given.—Social treatment may, usually does, run along with social investigation. Distinguish clearly between action taken in order to obtain information on the case (investigation) and action taken after you possess the information (result of investigation). Data here should in- clude all medical-social treatment on the case, and should be written in such a way as to make concise good reading. For example: " In the course of the above investigation many ward and outside visits were made, and much effort expended in getting the patient into a different frame of mind." Give all details of what was really accomplished. Do not attempt to put either the information on the case, or the social treatment under actual dates. It is to be written consecutively, but can be gathered at various periods, and dates would serve to confuse rather than to make the story clear. An occasional date can be put in where clearness of statement makes it expedient. When the preliminary folder history of the case is finished, all subsequent data should be added in the form of concise summaries covering a period of say a month, in order that the information may be sufficiently up to date to show what pos- sible social action would have to be taken by anyone attempt- ing to work with the patient. A concise, brief, summary analysis on the case at the end of the preliminary investigation is useful, bringing out the salient problems, causative factors, and possible cause of the success or failure of our medical-social treatment. This is not the same as our "Social Background for the Medical Condi- RECORD FOR HOSPITAL SOCIAL WORK 43 tion,'' but includes and enlarges on that, and may add present condition and future social and medical prognosis on the patient. All correspondence on the case, which it is desirable to keep, should be filed in the folder, or a summary may be made and letter destroyed. Avoid summaries of letters when letter itself is included, note merely by a few words that letter re- ceived, or sent and add (see letter of June 3, 1920)." CHAPTER V some further use of the extension record system One of the objections which has sometimes been brought against the use of an individual, as opposed to a family type of record, is duplication of recording. With the system which I have been trying to describe it is possible to start with the 5x8 record of one patient, add two or three Short Service cards for different members of the family, then start an Exten- sion Folder, and have all further recording on individuals in it, bringing the whole together in the files by means of red stars on each record, thus procuring what is in effect a family record. Obviously we do not attach an extension folder to a short service record because the use of such an extension record implies that the case is one which includes a real social problem, and as such has required more recording. It is also possible, and advisable, when 3x5 cards are added for other members of the family, to indicate on these short service cards that further identifying information is on the 5x8 record. We underline on each record, under '' Rela- tives" with red ink, those members of the family dealt with in any way, whether recorded socially or not. This method helps anyone reading the record to evaluate our responsibilities. The charge is sometimes made that there is duplication in this method of having individual records for different mem- bers of the same family. I do not think that this charge has ever troubled me much. Partly, perhaps, because I have long been accustomed to the use of hospital records, which are, of course, always individual. It has seemed to me logical to have separate records for different individuals who, while they happen to be members of the same family, yet present different social problems with which the hospital social worker, unlike the specialized social agency outside, is obliged to at least try and deal. Unmarried maternity; phthisis needing segre- gation ; child placing; change of employment for an industrial accident case, may all be met with in different members of the same family. If a single family record were made one 44 RECORD FOR HOSPITAL SOCIAL WORK 45 would have to record each individual under distinct headings, and search through the record to find them. What would be in common would be relationships, inheritance, perhaps re- ligion and address. methods of collecting record data Offhand dictation of such summary record material as I have been describing would be impossible for most of us. For taking first interviews case workers are furnished with notebooks, one side of each page being printed with a few topical headings, similar to those on the record card, and for the convenience of the typist, preferably in the same logi- cal sequence. When a social record is decided upon the worker can fill in as many of these headings as are found feasible at the first one or two interviews, mark the slip "5x8" or '' short service'' as planned, detach it by means of perfora- tions and hand it to the typist. The latter will transcribe the record, initial it as "done," and give it back to the case worker. The slips can be pasted back in the notebook if de- sired, and in any case form convenient desk memoranda for future cheeking up of the month's work. After the first record slip has been handed in and tran- scribed, all additional data is handed in on plain slips of paper. For the convenience of all concerned the workers are instructed to try and write legibly (a rare virtue), and to preserve uniformity in arranging the record material on the additional data slips: Name of patient, surname first, upper left-hand corner; number of record (unless current month), or if "Short Service," upper right-hand corner; data to be arranged under required headings, write on both sides of paper, number each side. After the data has been tran- scribed, the slips should be handed back to the worker both in order that she may check up, as was said above, her record material, note what corrections are needed, and also that she may place them back in her notebook if she so desires. For convenience in statistical checking up of the month's intake, to give opportunity for rearrangement of the kind of record selected, and for other reasons, we have found it con- venient to keep all the records for the current month separate, until after the monthly statistics are completed, and to delay numbering the index cards and 5x8 records until this time. 46 RECORD FOR HOSPITAL SOCIAL WORK While this necessitates looking in an additional place in the files when trying to locate a patient, it is quite essential to ensure accuracy in filing. The monthly checking is done by the worker who has charge of record statistics, and the stenog- rapher. An effort should be made to have the monthly statis- tics completed, and the records filed in place not later than the end of the first week of the month following. Besides saving the time of the stenographers, and therefore expense and space, the avoidance of direct dictation, which forms a necessary part of my record scheme, has this to recom- mend it, that it is more apt than the old way to induce the deliberate thinking so essential when one is trying to get a work picture. When record material is dictated directly to the stenographer, immediately, or soon after interviews or other case activity, undue importance is apt to be given to many things which, after a lapse of time, prove in perspective to have little real, or permanent, value towards the solution of the case problem. Such recording is apt to be merely "a record of how the worker has spent her time," not of what has actually been accomplished. One of the objections brought against the summary method of recording is that it does not show the day-by-day steps in the work sufficiently to allow anyone not previously familiar with the case to carry it on in the absence of the original worker. Up to the present these are objections to be brought against any system of recording. Experience in the use of the chronological method has served to convince me that the rec- ords of very few people are kept so up to date, or in such shape, that they would immediately be available as showing the last phases of case activity. A worker seldom or never records all that is in her mind as forming the basis for her conception of her case problem, and social treatment. I used to find, while I was doing case work, that in order to get my work handled as I wanted it to be in my absence, on vacation. for instance, I had to give a great deal of explicit direction to the one who was to take my work during my absence, and I worked out a special method of doing this. This may have indicated that my method of recording was at fault. It is my firm conviction, however, I am speaking of hospital social work, that a case worker has a great deal of more or less inde- terminate information, impressions from personal observa- RECORD FOR HOSPITAL SOCIAL WORK 47 tion, on much of which she forms her case work plans, which is of great value to her, but which will not, and should not, be transcribed in permanent record form. It often happens also during the course of active case work that many day-by-day steps have to be tentative, the next step depending upon where the last one has led you The custom of dictating every day has grown infrequent in most departments of hospital social work, at least. Moreover a chronological record of steps taken does not, as a rule, serve to show what steps are contemplated. We have found that loose-leaved notebooks and calendars for the collection of data, and as memorizers for temporary use, are essential, and that it is also necessary to give much special thought and training in their use. One of the disadvantages of the summary method of recording is that the generality of workers seem unable to distinguish between conservatism and meagreness in recording. When asked to leave out unes- sential they are prone to omit necessary details. Training in the proper use of notebooks to record current activities from which later the permanent record material is selected is neces- sary for this form of summary record. The use of abbreviations has grown to be quite common among hospital social workers as in other forms of social case work There is a peculiar temptation to this when the record space is limited as on our cards. Certain data should never be abbreviated, as proper names of persons or places, addresses, medical diagnoses. Abbreviations should not be used for the sake of saving the time of the writer when space and clearness indicate the need of greater length. In our folder record we discourage the use of any abbreviations, because we aim at a good readable, narrative form. It is extremely desirable that each department should make out a list of permissable abbreviations, and discourage the use of others. It would be helpful if such a list could be standardized among the dif- ferent departments of hospital social work throughout the country. Allowance would have to be made, of course, for abbreviations of names of local societies. It would also be helpful if an effort were to be made to standardize the different statistical terms in common use among hospital social workers and others. At present it is impossible to judge between the intakes of the different de- partments and the amount of work which each is carrying as 48 RECORD FOR HOSPITAL SOCIAL WORK expressed by their monthly statistical sheets. The question of terminology is one which is becoming of great interest among social case workers in general. A WORD ON STATISTICS The collection of statistical data forms such an important part of any record scheme that I have included a list of our statistical headings. We have a balance sheet made out each month. These twelve balance sheets at the end of the year form a useful method of collecting some of our annual statis- tics. During the six and a half years since the beginning of the work, while we have discontinued certain headings which experience had come to show us as unnecessary or superfluous, for a statistical sheet, and have rearranged and enlarged others,* the sheet as given on opposite page is on the whole similar to the one we used for our first month. It is essential, I think, that the person "in charge of statistics," who goes over the sheets with the case workers, checking them up, should be herself a case worker, or one familiar with case work tech- nique. Social statistical material is not as dry as might ap- pear. It is, after all, the final statement of what was done on, and with, the human intake. I think case workers should be trained to use their statis- tical sheets in close connection with their case records. I have long had the practice of going over a rough draft of their monthly sheet with most of the case workers. This custom stimulates the case workers, both to get the monthly intake all together for concrete presentation to another person (a super- ior officer), and offers an unrivalled opportunity to judge of a case worker's ability, the character of her work, her attitude of mind, her grasp of proper record writing, whether she understands the implications of the statistical headings. Such an interview once a month, with a moderately sized staff, should not be too severe a tax on the Director's or Head Worker's time. It is surely very definitely the job of the one directly responsible for the "hiring and firing" of workers, as well as for the ultimate character of the work as a whole. Too often, I believe, the oversight of records and statistical material has been either entirely omitted, or treated as a matter of secondary importance, and as beneath the dig- nity of the Head Worker, or Chief. There can be no question, * See Chart of Monthly Statistics. Ci O ~2 Referred to Insti-tution or Agency Q Id !i Mt3 •S s "Hi* CD o c No. of Record is CD 3 >, o a) ■r c u ° v. i-i a-: CT d 0) a 0 5x0 .t; o u 1 * -- Size 12 x 16 inches, ruled as indicated. Headings and ruling on both sides. The balance sheet is similar. It will be noted that there are four sources from which™ worker can obtain her patients. Under reinstated it is necessary to indicate those reinstated for the first time durine the cur^t year as these alone should be included in the annual statistics, because, while it is not desirable to have, to do so the sTme oatiencan be reinstated twelve times a year, but can only be noted as "first time" once. We have found from experience that the Iwe six headfngs meet all our requirements as to statistical inactivity. A few words on three ways of leaving a case active at the end of the mon^th ar^ pVrhaps. necessary in order to explain our use of them. The "refer" to an agency or institution means that the Patient. Pf a ward oatient' has beeA discharged from the hospital, and the agency has actually assumed its share of responsibility. A visit by the outside ae£nto a patient? in the ward or. in the case of a discharged patient, to the home, to see if the agency will conclude tp assume some resoonsibihty is not wUh us counted as a "reference" at all. but as merely contemplated action. The second active heading "Followed inThe Home'' is us«d to express activity when, at the end of the mDnth. the patient snot actively ''referred" to an agency, and we are our- selves stilHctive. It is a "blanket" term. "Pending" is only used in the case of patients still in the ward; social plans, if .made on these cases before discharge, are with us only plans not action taken. 50 RECORD FOR HOSPITAL SOCIAL WORK of course, that it is desirable to have a Record and a Case Supervisor, apart from, and in addition to, the Chief, when funds and equipment warrant it. But even so in justice to the work, and the workers, such monthly conferences as I have referred to are of great value, and worth the time occasion- ally spent on them. When it becomes unfeasible for the one in charge of the work to see all the case workers once a month, either because of other more legitimate calls upon her time, or the increase in the number of the workers, it should still be possible for the Director or Head Worker to occasionally select certain workers for this monthly interview on the intake. These may be selected because of their new- ness in, or apparent lack of adaptability to, the work, which seems to indicate the need for special training. Selection may also fall on workers who are carrying a good deal of responsi- bility for others, in which case the individual interview will include a general report on a special branch of the work. The one in charge of the work as a whole needs these occasional monthly interviews on the case work as much, if not more than, the case workers, in order to bring herself into touch with the work as a whole. Too often, I think, the one directly respon- sible for the conduct of the work allows herself to get too out of touch with as important a part of it as the case work. RECORDS AS RESEARCH MATERIAL It is necessary, I believe, to bear in mind in regard to per- haps the greater bulk of hospital social case records, that the material in them will not, as a general thing, be of much value either for research work, along hospital social work lines, or for the use of those outside the hospital wanting to make studies in Health Insurance, the effects of sickness on economic efficiency, the effects of material relief on social efficiency. Social records, day by day, short enough to be prac- tical, or feasible, to keep, explanatory enough to serve as memorizers and guides to action taken, or contemplated, reser- voirs for monthly and yearly statistics, are not fertile as fountains of such information, however it may flatter us social workers to think they are. Questionaires, special studies, with carefully expanded headings, will continue to be necessary. I heard a wise social worker (Miss Zilpha D. Smith) say once that "if you want to get any special information out of a RECORD FOR HOSPITAL SOCIAL WORK 51 social record you must arrange beforehand that it shall be put in." It would undoubtly be feasible, as noted above, in certain special types of cases, as unmarried maternity and illegiti- macy, where there is active interest and discussion in regard to the causative factors and treatment, to arrange to include cer- tain headings in the extension folder, and this was. one of my chief reasons for wanting a record form which permitted this occasional indefinite expansion. There can, of course, be no question that social records must be available for teaching and demonstrating social case work. This is one of their great excuses for being. I think, however, that unless used with very good judgment, there would be grave danger of turning a practical record into a sterilized questionaire. THE USE OF RECORDS AS REPORT SLIPS Another use which has been claimed for hospital records is to show the doctors what we are doing "to brinp; to their notice certain things which are in the background of the medical history of the patient.'' While I fully believe in the urgent necessity of emphasizing the social, as well as the medi- cal, background of a hospital patient's history, in connection with treatment, and that it is part (and a most difficult part) of a social worker's function to lay this emphasis and convey this information, I do not think that the regular social record is the proper means to employ. It is too (socially) technical. Concise, informal, verbal, or very brief and to the point, written reports serve the purpose better. Hospital physicians are apt to be very busy, pretty well absorbed, most of them, in the practice, and teaching, of what they at present regard as more definite medicine. The conveying of information in few words, yet adequately, is part of the technique of a good hospital social worker. It is quite useful in other walks of life. CONCLUSIONS In conclusion there are certain things which we, as hospital social workers, would do well to bear in mind: I. That social case work is the one thing which can really distinguish social workers within a hospital as forming part of a recognized, professional treatment group, needing training along as special lines as medicine and nursing, but radically 52 RECORD FOR HOSPITAL SOCIAL WORK differing from both, although offering as great opportunities for service to individual human beings; and that an important part of the technique of this profession is good, adequate, but practical, case recording. II. That no form of record that can be devised will do away with the necessity for selective judgment on the part of the case worker as to what case to accept for social recording, what social treatment to give, how to give such treatment to the best advantage, and it is well that this is so. The indi- vidual judgment of the case worker will always influence the decision, so there will, inevitably, be some lack of uniformity, not only among different departments of different hospitals, but even within the same department. To lessen this lack of uniformity within certain limits is one of the purposes of case and record supervision. III. That while admitting that to succeed in writing a summary picture record, such as I have in mind, in few words, as on the short service and the 5x8 cards, and in readable story form as in the extension folder, is not easy, and demands a certain intellectual and educational background. But do we not want all.hospital social workers to be able to stand up to such a test ? IV. That the realization of the ultimate purpose and real value of case recording will do away with the possibility of overhearing such expressions as: "Why waste hours, and tons of paper, in writing records which nobody ever reads?" "I don't write up my records because I am more interested in the human side of my work." V. That while it may be difficult to bring about the unsel- fish team play necessary to enforce proper case recording by care, by patience, by diplomacy, by firmness of purpose, and now and then the resignation of someone unwilling, or unable, to cooperate, it can be done. CHAPTER VI ILLUSTRATIVE RECORDS In selecting illustrative case material I have tried to show a few of the different phases of our work. In choosing from actual case histories those that are suitable for publication, one meets with some difficulties. Even with all identifying infor- mation as names, addresses, hospital numbers disguised, many of the most typical cannot be reproduced. One of the reasons Fig. 9. Marble, falter Case No. 5799 625 Dearborn St., East Boston March 19, 1920. Fa. Walter Uo. Eva, dead. Bro.James Bro.Roy Bro.Max Bro. Leo Bro.Frank Sis.Clara Surgical Service (O.P.D.) Sis.Mary Miss C for this is that they may contain certain data unsuitable for publication. In the case of some of the 3x5 and 5x8 cards it was found necessary to widen the interspacing in order to be able to get a clear photograph, so that we had to select those which would be illustrative even with some of the data eliminated. With this latter exception and the removal of identifying information the material is a record of actual case work with real patients. In addition to the short service records referred to on pages 20, 21 and 22, and Figs. 6, 7 and 8, I have selected the following as examples of our 5x8 record. The two first are without, 53 Fig. 10. Case No. 5799. Department of Medical-Social Work OF THE Boston City Hospital Date March 19, 1920, Worker Miss C Name Marble, Walter Address 625 Dearborn St,, East Boston Medical Diagnosis Traumatic Amputation of leg (below knee, right). Referred by Dr. D___(Executive Asst.) why pt. lost leg some time ago and was trtatted in this hospital. Asks helpChurch in getting artificial leg. Can ve do something for him? Previous Medical Care East Boston Relief Station, 1910 (following accident). Occupation Watchman. industry Leather Factory. Social Problem Physically Handicapped. Plan Investigate resources and if possible see that an artificial leg is provided. Previously Registered C. E. of I? Ho . j5. W. Age Wks. mos. Date of Birth Jan. 3, 1904 Place of " B08t0n How long in Boston Life - ■ « u.s. Life s. i/. yC-. Nationality Scotch-American Citizen Yes Settlement Bo8ton Religion Roman Catholic Star of the Sea yrs. lfiHouse No. Ward Service Admitted Discharged 0. Surg. 91185 Mar. 19/20. P. Dept " " No. First visit Financial Condition Pt.*s wages $10.00 wk. Bro. James earns $20.00 wk. Fa.'a wages when working $40.00 wk. Pays Hamden St. Home $3.00 wk. J.B.Ins. Co. $1.00 wk. Resources St. Mary's School. Father F. Stone A Bush, 764 Atlantic Ave. (employers). Mr. B.,456 Tremont St., Boston. Dr. C.,5 Gale St., Boston. Social Background to Medical Condition An overgrown boy; handi- capped in school and industry by the loss of his leg at the age of six years; second oldest of a large motherless family; having a good honest and hard working father. Fig. 11. Fa. Salter, 48,b.Scotland, add.as above,occ.foreman,Bro.Max,12,b.Boston,VI Gr.St.Mary's School. f.L.Smith Co.,6 Bay Ave.,Boston. Bro.Leo,11,b.Boston,VI Gr.St.Mary's School. Mo. Eva,45,b.Lynn,d.Jan.'18.B.C.H.House diag.In- Bro.Frank,10,b.Boston,IV Gr.St.fiary's School. complete Mis carriage. Med. Diag. Lung abscess . Sis,. Clara, 7, b. Boston, I Gr.St.Iary's School, Bro.James,19,b.Boston,occ.machinist,add.as above. all add.as above. Bro.Roy,14,b.Boston,occ.scholar,VIII Grade,St. 8is.Mary, b.Bos ton, add .Hamden St .Home. Mary's School. Add.as above. Action taken Conf .with J.H.D.,Factory 8upt.,with teacher, Parochial School; with Father F.with Captain H.Station 7; with Mr.A.(employer) with Mr.B.,S.f.Artificial Limb Co. March 31/20.Fol. in home. Apr/20.Took pt. to Mr.B.,S.W.Artificial Limb Co.for measurements. Vis.to home. Tele- phoned Dr.C.for office appt.to see pt. Telephoned Mr.B.for use of auto. May 31/20,Followed in home. June/20. Pt.taken in auto to Dr.C.'s office. June 30/20. Followed in home. July 30/20. Left in care of relatives. Remarks Factory Supt.J.H.D: Pt.good worthy boy, strong as ox, could earn more if not handicap- ped. Present Job easy,watches bundles of leather during transf.from trucks to elevator to see that none are stolen. Teacher: Pt.had wonderful mo.,interesting fam.,handicapped in school by loss of leg,left in VII grade.Father F: Fam.deserving,worthy of interest. Captain H: "Good fam." Home visit: Bro.Roy acting as housekeeper, home clean and orderly. Fa: Had promised pt.leg,un- able to pay for it. Although present income seems large he has had various housekeepers who have incurred debts, drank, etc. Owing to this, high cost of living,and large fam.he cannot get any- thing ahead. Ho rels. available, Fa.appears honest, hard working, ambitious for fam. Has sys- tematixed housekeeping for children. Mr.B.,Arti.Limb.Co.: Leg will cost $100.00.Mr,D.(employer) as result of interview,sent check for $85.00. Remainder of bill $15.00 received from Special Apparatus Fund (Hospital). July 30/20. Leg approved by Dr.C. Bill pd. Pt.working. Fa.secured housekeeper. 56 RECORD FOR HOSPITAL SOCIAL WORK and the two last with, an extension folder. To get a clear idea of the scheme the different parts that go to make up the record should be read consecutively. Case No. 5799: A physically handicapped boy where we were asked to provide an artificial leg. Index card Fig. 9, 5x8 record No. 5799, Figs. 10 and 11. Case No. 5964: An unmarried mother whom we placed in the care of a private society within a month. Index card Fig. 12, 5x8 record No. 5964, Figs. 13 and 14. Case No. 2684: Illustrative of work with an individual extending over some years, and involving a radical change, not only in the medical diagnosis, which only long and per- sistent medical-follow-up and social case work could have dis- closed, but also in the social treatment which was implied in this change of medical diagnosis. Index card Fig. 15, 5x8 record No. 2684, Figs. 16 and 17, and attached folder No. 2684. Case No. 5497: Is illustrative of the use of our record for when, beginning with a 5 x 8 card for an individual patient, it came to include definite social case work for other members of the family of a dependent widow, thus indicating the need of an extension folder within which to focus the social treatment of the family unit. Index card, Fig. 18, 5x8 record No. 5497, Figs. 19 and 20, short service records, Figs. 21, 22 and 23, and attached folder No. 5497. Fig. 12. Borth, Marion Case Ho. 5964 41 Windsor St., Dorchester June 7, 1920. Fa. John Gynecological Service Mo. Margaret (House) Bro.John Bro.Daniel Sis.Agnee Mat. Grandmo. Margaret MacDugal Worker, Miss A. Fig. 13. Case No. 5964 Department of Medical-Social Work OF THE Boston City Hospital Worker Miss DaWJua^T 1920. Lss A. T Name Horth, Marion Address4l Windsor St.,Dorchester Medical Diagnosis Maternity. Referred by Dr. Weed, House Physician. why pt. is a single girl delivered of a normal male child, probably needs advice. fl. W. Age Wks. mos. Date of Birth Oct.. 31/99 Place of "Halifax, Bova Scotia Ward S How long in Boston . 4 year8 « " - U.S. 4 years S. M. W. NationaiityBorwegian-Ameri can Citizen Ho . Settlement No . Religion Baptist Church Avery Street yrs.21 House No. 404068 Service Gy n . Admitted June 2/20 Discharged June 16/20 Previous Medical Care pr£ vate U.D. for in- fluenza 2 years ago. Occupation Waitress • industry Private families. Social Problem Unmarried mat emit y. Plan To reprehend alleged father of infant; to place patient and child with a suitable ■Wvt&sly Registered C. E. of I? Ho . 0. P. Dept. " " No. First visit Financial Condition Wages $12.00 wk. and keep. Has sent Mother half. No insurance. Ho debts, no savings. Resources Agnes North (sister), 386 Rut ledge St.>Can« ton. Robert Brewster,alias Gray (alleged fa.). Talitha Cumi Home (Miss G.),Forest Hills St'.| Jam- aica Plain. Children*s Aid Soc.(Miss B.),43 Haw- cfccial BacKgrouirU wraeaioaf Condition *_ •♦♦rag*4VM VilcrVi strung girl"of alien birth;educated in rural dis- trict schools; came to America at an early age;has been employed as domestic servant. Propinquity ap- pears to have been-a contributing cause to her sex delinquency. Fig. 14. Relatives Fa. John, b. Nova Scotia, d.during pt.'s child- add. Sydney, N.S. hood, occ.was a farmer. Bro. Daniel, age 32, (a), b.Nova Scotia, occ. Mo. Margaret,age T 60 yrs.,b.Nova Scotia,occ. farmer, add. Sydney, N.S. housewife, add. Sydney, N. S. Sis. Agnes, age 26, b.Nova Scotia, occ.dom- Mat. Grandmo. Margaret MacDugal (w),b.Scotland, estic, add.386 Rutledge St., Canton, add.Sydney, N.S. Mass. (place of employment). Bro. John, age 38 (s), b.Nova Scotia, occ.farmer, Action taken Visit to Municipal Court (Roxbury Division). Visit to sister at place of employ- ment. Conference with Dept. State Aid ft Relief (Miss C). Refd.T.Soc.(Mls8 S.). June/20. Ut- ter to T.Soc. (summary of court action obtained through Legal Aid Soc). Letter to pt. June 16/20. Admitted to F.Maternity Home for conv. care. June 30/20. Trans I. to T. Society. Remarks Ft. appeared mentally normal, high grade. Stated: While in employ of J.Lear,Prides Crossing, became pregnant by the house-man, Robert Brewster,later learned he, was married,had an alias Gray,and wife Jane Jones. For the past 4 mos .had been at service with Mrs .J.,35 War- saw St.,-•*,Mass.(verified). Sis.Agnes having been located at place of employment was inter- viewed, furnished most of data on pt. She said she had come to U.S.2 yrs .before pt.,had been in more or less close touch, had always thought pt."a good girl," had known nothing of trouble. In spite of disgrace,realised need of giving infant a good start,favored pt. being placed with baby. Would communicate with mo. Lator sis: Mo. did not want pt. to return with baby. Mrs .Brew- ster (wife of alleged fa.)interviewed: She had located pt. through letters which latter had sent to Brewster. Mrs.B.visited pt.'s lodging house, and came to hosp. She said Brewster was "no good." Had married him just before her own baby was born. Had lately lost track and been trying to find him because was again pregnant by him. B.had been trying to persuade her to have an abortion. He had once got a 15 yr.old girl into trouble and had been brought into court for it. June 16/20. Pt.'s future social care assumed by T.Soc. Latter: "Fine type of girl. Soc. much interested in her." RECORD FOR HOSPITAL SOCIAL WORK 59 Anderson, Helen 65 yernon Street, Fa. Martin Mo. Jane, dead. Bro.Martin Bro.John Sis.Caroline Sis.Jane Miss Fig. 15. Boston. Case No. 2684 August 12, 1916. Surgical Service (House) Medical Service (House) Medical Service (O.P.D.) Fig IP. Gtsc No. 2684 Department of Medical-Social Work OF THE Boston City Hospital Date August 12, 1916. Worker Miss Ward C Service HI Surg. Admitted Aug.8/l6. $. W. Age Wks. mos. yrs. 18 House No. 452090 Date of Birth Jan. 9, 1898. Place of " Boston How long in Boston Li f 0 - « « U.S. Life s. t/. yfr. Nationality Irish-Ameri can Citizen Y68 Referred by Dr.T.,House Surgeon (resident) Settlement Boston Why Pt. needs convalescent care, is Religion Roman Catholic not able to work at present. Adhesions Church St. Mary's have followed an abdominal operation. Name Anderson, Helen Address 65 Vernon Street, Boston Medical Diagnosis Adhesions (chronic). Sept.'17. B.Cons.Hosp.O.P.D.Phthisis (incipient). 455880 F II Med. Oct.28/16. Discharged Sept .1/16. NOV.28/16. O. P. Dept.Med. " " No. 59760' First visit June 5/17 . Financial Condition Pt.'8 wages $6.00 wk. Bro.John's wag- es $7.00 wk.* board. Bro.Martin's wages $20.00 wk. Jan.1/17. Bro.Martin sent check for $12.00. Feb.2/ Previous Medical Caregt. Vincent's Hosp., Jan.' 16; 17. Pt.'s wages $4.00 wk. Appendicitis. Two other operations for adhesions. Occupation Packer industry RUOber Factory Social Problem ^^ ot Family Coordination. Plan To get medical history, provide con- valescent care, later get work. Previously Registered C. E. of I? No . ResourcesMrs.Jones,add.above (friend A landlady). Mrs, Robinson,65 Vernon St.,(employer).Infant's Hosp. (Supt.,Miss X.) Miss Z.,16 Dudley St.,U.Laundry (employer).Bos.Cons.Hosp.O.P.D.(Nurse,Miss Q.) Social Background to Medical Condition jj0 home. Ill for past year. Always delicate. Father irresponsible, moth- er dead, brothers indifferent. Patient apparently Introspective and somewhat neurasthenic. Educated at St.V.Orphanage. Flo. 17. Relatives Fa. Martin, 53, b.Ireland, add.185 Newton St.,Roz. Sis.Jane, 11, b.Boston,add.St.V.Orphanage. oco. V.Dept.,K.St.,not living with family. Mo. Jane, 48, b.Boston, dead. Bro.Martin, 25, b.Boston,occ.soldier,U.S.A.,works for Bost.E.R.R. conductor,2 G.St.,Roxbury. Bro.John,21,b.Boston,occ.assistant in C.Factory. Sis.Caroline, 27, b.Boston (m),(Mrs.J.B.). Action taken "Letter to St .Elizabeth's Hospital. Aug.31/16. Refd.to Boston City Hospital Conv.Home for 3 weeks. Sept.25/16. Letter to father. Sept.28/16.Refd.to Milton Conv.Home for 2 weeks. Oot.12/16. Refd.to Chickering House for 3 weeks. Nov.28/16.Refd.again to B.C.H.Conv.Home for 4 weeks. Dec.27/16. Refd.to Milton Conv.Home. Jan.,Feb.,March,April 1917. Followed in Home A O.P.D. May 31/17. Transf. to Infant's Hospital, Training School. Remarks®1*0• «I°nn: "Ean. scattered since death of mo.; pt. has been a 'little mother'; willing to do what he can for her, thinks elder bro. and fa. should help; latter a drunkard, not living with family. Hurt his foot through accident at present job where has worked 3 yrs." Oct.28/16 Convalescent care has been provided for pt. since Aug. 31/16. Is now at Chickering House. Latter'telephoned: Pt. ill and needs hospital care. Admitted B.C.H.,"observation." Later sent again to B.C.H. Convalescent Home and also to Milton Convalescent Home. Dec/16. Father re- married, new wife has 4 young children. Bro.Martin returned from Mexico.and got work with E.R.R Jan/17. Pt. examined by Dr.T.,Surgeon, B.C.H.,who advised work instead of convalescent care as pt. becoming institutionalized. Arrangements made with Mrs. Jones to give pt. board and clothes in return for light work. Feb.3/17. Supt.,Infant's Hospital: Will accept pt. as soon as opening occurs. In meantime obtained Job with Mrs. Robinson, 65 Vernon Street. Suitable outfit of clothing procured. May 26/17. Entered Training School, Infant's Hospital, became ill, readmitted to B.C.H. June 5 for "observation." (For further remarks, see folder #2684). 62 RECORD FOR HOSPITAL SOCIAL WORK This is the extension folder for case No. 2684, and should be read in connection with Figs. 15, 16, 17. DEPARTMENT OF MEDICAL-SOCIAL WORK* of the Boston City Hospital. Worker, Miss---- Case No. 2681 Date Aug., 1916 HOW THE CASE CAME TO US This young girl was referred by the Resident House Sur- geon because she was without a home and having had three operations with consequent adhesions, was in need of pro- longed convalescent care. The surgeon felt that she was in danger of becoming a chronic invalid. Medical Record.—Showed that between January, 1916, and August, 1916, the patient had been operated three times: At St. Vincent's Hospital, January, 1916, for appendicitis; at the Boston City Hospital, March, 1916, for intestinal ob- structions, and August, 1916, for adhesions. During this time she had been admitted to the Boston City Hospital five times, and the surgeons thought she was fast becoming introspective and neurasthenic. SOURCES OP INFORMATION Patient's Statement.—The patient stated that she was eighteen years old, born in Boston June 1,1898, was a Catholic. Her mother, Jane, had died thirteen years ago in the Boston City Hospital (diagnosis (?) of pneumonia). The father, Martin, worked in the ------ Department, was a heavy drinker, and neglected and deserted his children. He broke up home shortly after the death of his wife, placed patient and her sister Jane, aged eleven, at St. Vincent's Orphanage, never paying their board unless forced to do so. Her sister Caroline (Mrs. J. ----B. ----), aged twenty-seven, was in poor cir- cumstances, had a large family and did not get along with the patient. Brother Martin, aged twenty-five, was a soldier in the United States Army, had not been heard from for a long time. Brother John, aged twenty-one, had an artificial leg and was assistant timekeeper in a large Boston factory. Upon leaving St. Vincent's Orphanage, where she had been eight years, she was placed by her father with Mrs. Katherine RECORD FOR HOSPITAL SOCIAL WORK 63 Smith, 3 Front Street, Brighton. Her father shortly after- wards disappeared. The patient then went to work at------ Company at $6 per week. She was abused and exploited by Mrs. Smith, until she finally found a good friend in a neigh- bor, Mrs. Jones, and went to live with her for over two years, paid $3 per week board, and kept on working at------Com- pany until she became ill, and was admitted to the Boston City Hospital, March, 1916. During all this time her brothers and father had left her to her own devices, and had taken no interest in her welfare. Statement of Brother John.—He said he received the in- jury to his leg while doing porter's work at the Boston factory where he had been working since November, 1913. Fell while washing a window, causing osteomyelitis, which had later necessitated amputation of the leg half way below the knee. He had an artificial leg, and had been assistant timekeeper at the factory for eighteen months. He claimed to be able to do very little for his sister as he was in debt for an outfit of clothing. Said he "did not see why he should assume re- sponsibility when there was an able bodied father and brother. He added that his father was a hopeless drunkard, "who had always shirked the responsibility of providing for his children, and always would do so.'' Mrs. Jones was visited. Statement of Mrs. Jones (friend and landlady).—She said that the patient had lived with her about two years up to August, 1916, during which time neither her father or her brothers had been to see her, or helped her financially. The patient '' was a good girl who worked hard in the factory, but spent her money foolishly without thought of the future." Mrs. Jones' own children were devoted to the patient. Mrs. Jones said she felt that she had done all she could for the patient, and that she could no longer assume any responsibil- ity, especially now that the girl was ill most of the time, but she was fond of her, and willing to befriend her always. (Mrs. Jones impressed the worker as being a splendid type, intelli- gent and kindly disposed.) SOCIAL ANALYSIS OF PATIENT The patient made a favorable impression upon all who came in contact with her, both in the hospital and outside. She has a bright, pleasing personality and makes friends easily. 61 RECORD FOR HOSPITAL SOCIAL WORK Is quick-tempered, impulsive and inclined to be extravagant. The latter quality is probably due to lack of early training in thrift. She is fond of a "good time," which she will obtain re- gardless of possible injur}- to her health. Is not afraid of work and is anxious to make her own way. Is grateful and apprecia- tive for kindness shown. She seems to have had no settled home since early childhood; to have been educated in a Catholic orphanage, delicate health always, ill many months. Mother dead; father irresponsible; brothers indifferent; no apparent reason yet found for her continued ill health. SOCIAL TREATMENT GIVEN After many vain efforts were made to ascertain the father's wishes and plans regarding the patient (both by visits and letters) a programme of convalescent care was carried through upon advice of the doctor. Part of this was paid for by her brothers, John and Martin. The latter had returned from Mexico, November, 1916, where he had been with the United States Army. After pressure from his employers, the Boston Elevated Railway Company, was brought to bear, he gave $12 and consented to aid as long as necessary. He shortly afterwards lost his job owing to irregular conduct and drink, and was unable to fulfill his promise. It was now ascertained that brother Martin was an arrested case of phthisis. At the age of seventeen, he had been to R------ and W------ Sanatoria where he remained for five years. Patient was sent to the Boston City Hospital Convalescent Home August 18, 1916, to September 28, 1916, from there to Milton Convalescent Home for two weeks, and then to------, where she again became ill and was readmitted to the Boston City Hospital for observation. After this she was again given six weeks' convalescent care. February 13, 1917.—As the patient seemed fast becoming institutionalized, Dr. ------, Visiting Surgeon, Boston City Hospital, was consulted and advised work instead of conva- lescent care. As she had expressed a strong desire to take the nursery maids' course at the Infant's Hospital, the superintendent of that institution was consulted, and through her the patient was placed with Mrs. Robinson, 65 Vernon Street, Boston, RECORD FOR HOSPITAL SOCIAL WORK 65 as assistant nursery maid at $4 per week, until such a time as there should be an opening in the training school. At this time her brother Martin was induced to supply funds for a suitable outfit of clothing. May 26, 1917.—Patient entered the training school at the Infant's Hospital, but again became ill; had to leave after a stay of two weeks, and was readmitted to the Boston City Hospital for "observation." Note.—The father had in the meantime remarried, De- cember, 1916, a Mrs. Kate Mears, a widow with four children— Jimmy, five; Carol, seven; Ethel, nine, and Timmy, thirteen. Step-mother's Statement.—When interviewed the new step-mother seemed a kindly, intelligent woman. She said her first husband died of phthisis, and the child Ethel was in the Mattapan Hospital for Consumptives. She herself was also an arrested case of phthisis, and a patient at the Boston Con- sumptives' Hospital Out-patient Department. She said she was willing to make a home for her step-children, and had already taken patient's younger sister from St. Vincent's Orphanage, and would do her best by the older one (our patient). She said her first husband had been "sober and a good provider." The house in which the patient's father with his new family were living was a ramshackle old place, cold and meagrely furnished, but spotlessly clean. Owing to her increased ill health and consequent read- mission to the Boston City Hospital, a consultation had been arranged between the Surgical and Medical Services by Dr. ------ and after the patient had been sometime under ob- servation in the medical ward, but without any new diagnosis being determined; she was finally discharged to the Medical Out-patient Department of the Boston City Hospital by Dr. ------in June, 1917. She was at this time living with her father and step-mother. Soon after, the father again resumed his drinking habits, became abusive and ordered our patient out of the house. Being very unhappy she went to stay with the mother of a friend of her brother John: This friend, Mary Brown, 285 I Street, South Boston, John married in July, 1917. As the patient seemed unhappy and discouraged, close touch was kept with her at this time, and, acting on the advice 5 66 RECORD FOR HOSPITAL SOCIAL WORK of the physicians at the Boston City Hospital, it was decided to send her to the Boston Consumptive Hospital, Out-patient Department, for a special examination. A temporary job was also found for her as clerk in the ----— Laundry, 16 Dudley Street. Miss Robinson, the manager, was interested, and allowed the patient to attend the clinic at the Boston Consumptive Hospital, where a diagnosis of suspicious phthisis was finally made. Brother Martin who had entered the United States Army as soon as war was declared, was communicated with, and arrangements made to have his allowance of $10 per month made over to the patient. September i, 1917.—The Boston Consumptive Hospital Out-patient Department: The patient has been diagnosed a positive case of phthisis, and placed on the waiting list for a state sanatorium. (This was about a year since we had first known her.) October 18, 1917.—As the patient was rapidly failing in health, and as conditions in the home of her brother John's wife's family were unsuitable, her admission to the Mattapan Hospital was secured. (The In-patient Department of the Boston Consumptive Hospital.) October 26, 1917.—Patient's sister Caroline (Mrs. B.) came to the Surgical Out-patient Department: medical diag- nosis, cervical adenitis, and was referred to the Boston Con- sumptive Hospital Out-patient Department, where she had been treated for two years. The diagnosis was a question of phthisis. Miss Cummings, the nurse, reported: sister Caro- line's home conditions—a slatternly, badly kept house, and a drunken and abusive husband whom Mrs. Brown had taken to a police court for non-support October 11, 1917. November 2, 1917.—Patient was transferred from Matta- pan to the State Sanatorium at------. Previous to this, she had received $10 from the United States Government, the Oc- tober instalment of brother Martin's pay. With this, she partly paid her board and other debts. Mrs. Brown, the land- lady, agreed to cancel the rest of board bill. A pair of glasses and clothing to supplement her outfit was supplied through our Special Relief Fund at cost of $9.87. This the patient was to repay as she got the allowance from brother Martin. A little later brother Martin who was sent abroad with RECORD FOR HOSPITAL SOCIAL WORK 67 Company 1, 101st Regiment, Expeditionary Force, wrote that he was sent back from France owing to illness and was in a hospital in Hoboken, New Jersey. A letter was received from M. A., a patient at the same State Sanatorium where our patient had been admitted. This girl had been at the Sanatorium six years, was at this time an employee, and, being well known to one of the social workers at the Boston City Hospital, the latter had written asking for friendly interest and encouragement for our patient. M. A. was also a confirmed optomist. Her answer to our let- ter asking her interest stated that our patient was '' doing very well now. She seems to have a happy disposition, so I guess will get along all right. She was quite sick for a while when she first came. I will keep track of her and befriend her." Patient had been supplied with outfit of clothes and she reported that she was allowed to come home on short visit but had to return after a few days as she became very ill, and had been in bed the greater part of time until December, 1917. Brother Martin had been admitted to Mattapan Hospital September 10, 1917. The doctor at Mattapan stated that Martin was in the last stages of phthisis. Later he was dis- charged against advice December 19, 1917, and went to work with the ------ Manufacturing Company, address 13 ----. Landlady, Mrs.------. During all these months the patient had been encouraged to write details of her life at the Sanatorium. Her letters had been full of information about her surroundings, studies and examinations, full also of optimism rather remarkable under the circumstances. (Most of the correspondence has been re- tained in the folder. Lack of space prevents this inclusion in a published record.) February 7, 1919.—Patient came to Boston on a short visit. Reported she had been offered by Miss------, the superin- tendent at the State Sanatorium, the opportunity of taking a nurse's training, duties to commence March 4, 1919. The members of her family not being able financially to supply her with uniforms, etc., the Invalid Aid and the Lend- A-Hand Societies were asked to contribute. These societies gave $10 each, from which wash uniforms and aprons were purchased. The Invalid Aid had also promised to raise $10 more later to defray the expense of books. The Fragment 68 RECORD FOR HOSPITAL SOCIAL WORK Society contributed a $5 order for a pair of shoes. Arrange- ments were made with the Harvard Dental School (Miss L------) to do some necessary dental work, the cost to be defrayed through our Special Relief Fund. Laura Vale (fiance of brother Martin), address 508 Brook Street, Mattapan, who seemed a capable and intelligent young woman, holding a responsible position in the Cambridge City Hall, was interviewed and interested in patient. She assisted in the making of the outfit and promised to correspond with the patient at the State Sanatorium. March 4, 1919.—Patient left for the Sanatorium feeling very happy at the prospect of becoming self-supporting. March 19, 1919.—Miss Brown of the Lend-A-Hand So- ciety wrote enclosing check for $10, to be used to defray fur- ther expenses, and added, "Thank you for the good news about 'our nurse.' It is a pleasure to cooperate in helping so worthy a girl.'' Express order for $10 sent to patient. May, 1919.—Patient writes: "I am in love with my work and nobody in this wide world is happier than I am." She seemed to be gaining in strength and weight. She enclosed her first examination paper for which she got 100 per cent.; also a snapshot of herself. September, 1919.—Patient writes: "Have passed my pro- bation period (June, 1919), getting 93 per cent., and am now a full-fledged nurse, wearing my cap and bib." (A photo- graph was enclosed.) She seemed a little discouraged because she had had a hemorrhage shortly after, and was confined to bed for a few weeks. September 25, 1919.—When patient came to Boston to attend brother Martin's wedding, she was steered to the Boston Consumptive Hospital Out-patient Department for an examination of her throat, which had been giving her a great deal of trouble. As Dr. F------advised the removal of her tonsils under a local anaesthetic, Dr. H----, of the Throat Out- patient Department of the Boston City Hospital, was con- sulted and promised to operate before leaving the service in September. A letter was written to the Superintendent of Nurses at the State Sanatorium asking that the patient be allowed to come to the Boston City Hospital for an operation as advised by Dr. H------and Dr. F------. (See letters.) RECORD FOR HOSPITAL SOCIAL WORK 69 October i, 1919.—Patient admitted to Boston City Hos- pital, and as Dr. H------had gone to New York, Dr. F------, Visiting Physician, was consulted, and decided to operate, removing tonsils and adenoids. Patient was then sent to Bos- ton City Hospital Convalescent Home. She returned to the Sanatorium October 11, and wrote that she was happy to be on duty again. (A photograph was enclosed.) Brother Martin having been married September 21, 1919, to Laura Vale, he was now foreman at the ------ Company, getting $35 per week. His bride knew he had active tuberculosis, but nothing could dissuade them from marriage. Address, 25 Brook Avenue, Mattapan. Martin was very proud of patient's success, and had framed her examination papers, showing the 100 per cent, result of her examination. Patient also wrote that her father's address was now 15 Mountain Street, Roxbury, that he "is a new man since pro- hibition went into effect. Takes an interest in his home and family, and acts like a human being." A member of our Committee gave $10 to purchase shoes for the patient. Express order sent which patient acknowl- edged with gratitude. Clothing supplied and case made sta- tiscally inactive. December 23, 1919.—Dressing gown sent to patient as a Christmas gift from our Special Fund. (See letters.) May 20, 1920.—Reinstated. Patient came to Boston for week's vacation with brother Martin. She reported:'' Passed first year's examination with an average of 93 per cent. Feels fine with exception of trouble with throat." (See letter from patient.) She was steered to Throat 0. P. D. Dr. ------made a diagnosis of deviated septum, and advised operation when physical condition warranted it, in the meantime aural care once a month. She had saved $22 during the year, which she planned to spend for many necessary things, and as she was again in need of an outfit (dresses, aprons, shoe, etc.) in order to finish her training, an appeal was again made to the Lend-A- Hand (Miss Brown), and the Invalid Aid (Mrs. Waite). The former sent $10 (June 1st). Ten dollars was obtained through our Special Relief Fund and money order for the $20 sent to the patient (June 18, 1920), which was to be used for 70 RECORD FOR HOSPITAL SOCIAL WORK the renewal of uniforms and purchase of glasses, patient hav- ing lost hers in a snowdrift last winter. July, 1920.—Friendly letters continued to come from patient from time to time and gifts were also occasionally sent to tide her over. At end of July, patient wrote: Was examined in Eye Clinic of Worcester Hospital (Dr. II------) and obtained her glasses at cost of $9.45, also got her uni- forms, etc. Was feeling fine with the exception of her nose and throat. Dr. A------at the Sanatorium had advised having operation as her condition was now very good. Arrangements were made with the Superintendent of Nurses at the Sana- torium, to allow her time off in September (see correspond- ence for July, 1920), when she will come to the Boston City Hospital as the doctors there know her and are interested in her. The Invalid Aid Society sent check for $10 in July which was to be used for the future needs of the patient. The patient had also reported that she was greatly worried over her brother Martin's condition. He was said to have been having hemorrhages and had refused to return to Mattapan because his wife was pregnant and needed care. Acting on this report from the patient, brother Martin was referred to the Red Cross, as he was an ex-soldier and had been accepted for the army. While overseas his lung condition had become active and he had been sent back to the United States (see above). Red Cross: Martin admitted to Army Sanatorium at Groton pending investigation of his claim. September, 1920.—At request of patient arrangements were made for her admission to the Boston City Hospital September 21, 1920, for septum operation. She was dis- charged on September 24th in excellent condition and on September 25th returned to the State Sanatorium. She is to have two months' special training in obstetrics in the M------hospital. Left in own care. This patient had attached herself to the case worker who had known her so long, so that, while the worker is no longer with us, a correspondence is being maintained between them. RECORD FOR HOSPITAL SOCIAL WORK 71 Fig. 18. Palmer, James Case Ho. -5497 36 Bower Street, Roxbury September 2, 1919. Fa. Leonard, dead. Mo. Mary, S.S.Rec. Bro.Roy Bro.Leonard, S.S.Rec. Sis .Elizabeth Sis.Mary, S.S.Rec. Mat.Aunt, Eli zab eth Maloney Surgical Service (House) Aural Service Medical Service Eye Service (O.P.D.) Miss S Fig. 19. Case No 5497 Department of Medical-Social Work OF THE Boston City Hospital Worker Date September 2, 1919. Miss S. Name Palmer, James Address 36 Bower Street, Roxbury Ward f Service 11 Surg. Admitted Sept.2/19. Discharged Sept.l8/l9.