The Clinical Record in Medicine Part 2: Reforming Content and Purpose

Abstract

History of Medicine1 June 1991The Clinical Record in Medicine Part 2: Reforming Content and PurposeStanley J. Reiser, MD, PhDStanley J. Reiser, MD, PhDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-11-980 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptCase Records and Evaluating the Outcomes of CareIn the early twentieth century, a new form of medical evidence came to the forefront. While nineteenth century clinicians were using simple instruments to extend their senses and become skillful in physical diagnosis, investigators were developing methods of analysis that represented medical evidence numerically. In the twentieth century, numerical data gathered from such sources as laboratory reports, blood pressure readings, and temperature charts began to fill the pages of clinical records.At this time, it was unusual for either hospitals or physicians to keep reliable and detailed clinical records. In a 1917 commentary on the state of hospital records, John...References1. Epidemics III. In: Jones WH, ed. Hippocrates. Volume 1. Cambridge, Massachusetts: Harvard University Press; 1923:279. Google Scholar2. The art. In: Jone WH, ed. Hippocrates. Volume 2. Cambridge, Massachusetts: Harvard University Press; 1923:203. 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. 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Bulletin of the American College of Surgeons. 1919;4:5. Google Scholar13. Neuhauser D. Ernest Amory Codman, M.D., and end results of medical care. Int J Technol Assess Health Care. 1990;6:315. CrossrefGoogle Scholar14. Donabedian A. The end results of health care: Ernest Codman's contribution to quality assessment and beyond. The Milbank Q. 1989;67:245. CrossrefGoogle Scholar15. Reiser S. Creating form out of mass: the development of the medical record. In: Mendelsohn E, ed. Transformation and Tradition in the Sciences. Cambridge: Cambridge University Press; 1984:306-7. Google Scholar16. Pearl R. An Introduction to Medical Biometry and Statistics. Philadelphia: W.B. Saunders Co.; 1923:91. Google Scholar17. Auchincloss H. Unit history system. Medical and Surgical Report of the Presbyterian Hospital in the City of New York. 1918;10:30-72. Google Scholar18. Whipple A. The interval result system. Medical and Surgical Report of the Presbyterian Hospital in the City of New York. 1918;10:17. Google Scholar19. Weed L. Medical Records, Medical Education, and Patient Care: The Problem Oriented Record as a Basic Tool. Cleveland, Ohio: The Press of Case Western Reserve University; 1971:25;98-8. Google Scholar20. Grossman J. Physicians as Managers in Hospitals. London: Kings Fund Centre for Health Services Development; 1989. Google Scholar21. Reiser S. Malpractice, Patient Safety, and the Ethical and Scientific Foundations of Medicine. In: Huber P, Litan R, eds. The Liability Maze: The Impact of Liability Law on Safety and Innovation. Washington, DC: Brookings Institution; [In press]. Google 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.*Part 1, which appeared in the 15 May 1991 issue of Annals, focused on the use of case records in medical practice and teaching. 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Towards a model for flexible access to free text medical dataWe are the Stories we TellImproving the quality and ease of tracking invasive proceduresAttending to patients' stories: reframing the clinical task.Knowledge in Action 1 June 1991Volume 114, Issue 11Page: 980-985KeywordsBlood pressureChartsElectronic medical recordsForecastingInformation storage and retrievalResearch laboratoriesTemperature ePublished: 1 December 2008 Issue Published: 1 June 1991 Copyright & Permissions©1991 American College of PhysiciansPDF downloadLoading ...

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