The Clinical Record in Medicine Part 1: Learning from Cases

Abstract

History of Medicine15 May 1991The Clinical Record in Medicine Part 1: Learning from CasesStanley J. Reiser, MD, PhDStanley J. Reiser, MD, PhDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-902 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe clinical case record freezes in time that episode in life called illness. It is a story in which patient and family are the main characters, with the doctor serving a dual purpose as both biographer and part of the plot. The content of this biography varies greatly, reflecting its many purposes: to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions. In this essay, I discuss how clinical cases have shaped and reflected learning and action in medicine and how the document in which these cases are inscribed—the clinical record—has...References1. Epidemics III. In: Jones WH, ed. Hippocrates. Volume 1. Cambridge, Massachusetts: Harvard University Press; 1923:279. Google Scholar2. The art. In: Jones WH, ed. Hippocrates. Volume 2. Cambridge, Massachusetts: Harvard University Press; 1923:193, 203. Google Scholar3. Sydenham T. In: Dewhurst K, ed. Dr. Thomas Sydenham (1624-1689): His Life and Original Writings. Berkeley, California: University of California Press; 1966:60, 127-8. Google Scholar4. Morgagni G. The Seats and Causes of Diseases Investigated by Anatomy. Volume 2. New York: Hafner Press; 1960:127-8. Google Scholar5. Laennec R. A Treatise on the Diseases of the Chest. John Forbes, trans. New York: Hafner Press; 1962:398-400. Google Scholar6. RodinKey AJ. Medical Casebook of Doctor Arthur Conan Doyle: From Practitioner to Sherlock Holmes and Beyond. Malabar, Florida: Robert S. Krieger; 1984:199. Google Scholar7. Louis P. Researches on the Effects of Bloodletting. Boston: Hilliard, Gray and Company; 1836:64-5. Google Scholar8. Cannon W. The case method of teaching systematic medicine. Boston Medical and Surgical Journal. 1900; 142:32. Google Scholar9. Painter F. Extending the influence of a hospital. The Modern Hospital. 1918;2:356. Google Scholar10. Washburn F. The Massachusetts General Hospital: Its Development. 1900-1935. Boston: Houghton, Mifflin; 1939:117. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: A version of this essay was presented at a symposium, "The Medical Journal: Past, Present, and Future," held in honor of Edward J. Huth, Editor of Annals of Internal Medicine, on 14 September 1989. Dr. Huth retired as Editor on 30 June 1990. The papers from the symposium will be published in a Festschrift in his honor.*The second part of the article focuses on twentieth century improvements in the content and purpose of the case record. It will appear in the 1 June 1991 issue. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byMedical Records: A Historical NarrativeAn Introduction to Big Data Analytics Techniques in HealthcareElectronic Health Records: A Transitional ViewToward analyzing the impact of healthcare treatments in industry 4.0 environment—a self-care case study during COVID-19 outbreakThe patient record and the rise of the pediatric EHRElectronic Health RecordsBig Data Approach for Medical Data Classification: A Review StudyBig data in healthcare: management, analysis and future prospectsA Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient SettingPaper and electronic versions of HM-PRO, a novel patient-reported outcome measure for hematology: an equivalence studyNew Information Systems Supporting the Emotional Aspect of CareElectronic Clinical DocumentationCooperative Epistemic Work in Medical Practice: An Analysis of Physicians' Clinical NotesA hierarchical decision model (HDM) for exploring the adoption of electronic health recordsMaintaining the continuity of HIV-care records for patients transferring care between centers: challenges, workloads, needs and risksProblems with the electronic health recordKnowledge in ActionMedical record keeping as interactional accomplishmentAssociation of note quality and quality of care: a cross-sectional studyElectronic Health Record SystemsNational electronic health records and the digital disruption of moral ordersElectronic Versus Paper-Based Assessment of Health-Related Quality of Life Specific to HIV Disease: Reliability Study of the PROQOL-HIV QuestionnaireFrom Papyrus to the Electronic Tablet: A Brief History of the Clinical Medical Record with Lessons for the Digital AgeComputerized provider documentation: findings and implications of a multisite study of clinicians and administrators: Table 1Formulation: A Proposal for a More Structured, Longitudinal ApproachElectronic Medical Records (EMRs), Epidemiology, and Epistemology: Reflections on EMRs and Future Pediatric Clinical ResearchThe Clinical Record: A 200-Year-Old 21st-Century ChallengeMichael S. Barr, MD, MBAClinical methods: an historical perspectiveExperts and 'knowledge that counts': A study into the world of brain cancer diagnosisLes rapports de cas, vestiges du passé ?Clinical DocumentationClinical documentationMedical Record Reviews in Emergency Medicine: The Blessing and the CurseBarrier to Transition from Paper-Based to Computer-Based Patient Record: Analysis of Paper-Based Patient RecordsEmbodying the Patient: Records and Bodies in Early 20th-century US Medical PracticeHistorical Overview of a Psychiatric Clinical Information System: 'Peninsula Pathways'The Technologies of Time Measurement: Implications at the Bedside and the BenchStanley Joel Reiser, MD, MPA, PhDAn integrated electronic health record and information system for Australia?Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical DecisionsMedical Records, Patient Outcome, and Peer Review in Eleventh-Century Arab MedicineGeriatric Rehabilitation: What Do Physicians Know about It and How Should They Use It?Educating Primary Care Physicians in Geriatric RehabilitationAttending to patients' stories: reframing the clinical task.Case Records and the Classification of DiseaseManuel Varela, MDKnowledge in Action 15 May 1991Volume 114, Issue 10Page: 902-907KeywordsElectronic medical recordsForecasting ePublished: 1 December 2008 Issue Published: 15 May 1991 Copyright & Permissions© 1991 American College of PhysiciansPDF downloadLoading ...

Cite this work

No public copy is stored for this record, so only the metadata is cited.

Stored only when both papers are in the corpus — 76 citations exist upstream.

Papers that cite the same references — the relational fallback while embeddings are still backfilling.