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Ann Intern Med. 2010 Nov 16;153(10):671-7. doi: 10.7326/0003-4819-153-10-201011160-00012.

The evolving medical record.

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1
Division of Geriatrics and Gerontology, Weill Cornell Medical College, 525 East 68th Street, Box 39, New York, NY 10065, USA. els2006@med.cornell.edu

Abstract

Form dictates content, and the manner of recordkeeping imposed on us probably influences how we think about patients. At The New York Hospital, physicians began to maintain permanent patient case records in the early 1800s. Originally proposed and valued as teaching cases for medical students, these freeform patient records varied in quality and often reflected not just the medical care of the time but also the personalities of the physicians composing them. At the end of the 19th century, the change from retrospective to real-time recording of cases and the imposition of a fixed chart structure through the use of forms dramatically reduced the narrative dimension of the hospital course. Gradually, physicians found ways to circumvent these restrictions. Changes in record format, designed to manage increasing volumes of data, and physicians' responses to those changes parallel some of the contemporary threats to documentation posed by the electronic health record.

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