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[记录与描述:精神科记录的认知功能、存档以及对其重新解读并转化为病历]

[Documenting and describing. The epistemic function of psychiatric records, their archiving and reinterpretation into case histories].

作者信息

Ledebur Sophie

机构信息

Institut für Medizingeschichte, Berlin.

出版信息

Ber Wiss. 2011 Jun;34(2):102-24. doi: 10.1002/bewi.201101473.

Abstract

The paper attempts to reconstruct the writing of published case histories. Due to the establishment of a scientific classification system in psychiatry there were at the Charité several changes from the late 1870s onwards: (1) Not only was the documentation in the clinical records altered significantly, but also (2) the archive was reorganized into a double filing system and (3) the casuistic made a development from describing seldom or sensational cases into a mode which aimed to unfold psychiatric theory through 'typical cases'. Original medical records, the internal documentation of psychiatric observation, will be compared to their published version. Both, the narrative of a case study and the documentation in the clinical records reveal performative processes of observation and documentation.

摘要

本文试图重构已发表病例史的撰写情况。由于精神病学科学分类系统的建立,自19世纪70年代末起,在夏里特医院发生了几项变化:(1)临床记录中的文档不仅有显著改变,而且(2)档案被重新整理成双重归档系统,以及(3)病例报告从描述罕见或轰动性病例发展为一种旨在通过“典型病例”来阐释精神病学理论的模式。原始病历,即精神病学观察的内部文档,将与其发表版本进行比较。病例研究的叙述和临床记录中的文档都揭示了观察和记录的实践过程。

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