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A HISTORICAL PERSPECTIVE

Medical record keeping evolved during the early part of the twentieth century, before there were health care delivery teams and free-floating hospital-based specialists. A physician took care of his own patients, and patients generally had only one physician. When a consultant was used, the consultant consulted; he did not take over the care of the patient.

Hospitals provided nursing, custodial, food, and hotel services. Nursing was low-technology patient care. Little laboratory work was performed, and the physician usually participated in this work himself. The nurses, often nuns, were available night and day. They knew the patient's condition and needs, and they talked to the physicians. Medical records served as documentation but were not a primary vehicle for communication between health care providers. Simple narrative reporting was used because there were few events to record and little need for retrieving information from the record.

Modern health care delivery has abandoned the one physician-one nurse model for the health care team. Many physicians care for a single patient; some of them are unknown to the patient and the primary physician. Nurses are employees with regular shifts and multiple responsibilities. The medical record is now the basic vehicle for communication among members of the health care team. Confusion arises because records are also kept to satisfy accreditation standards, legal requirements, accounting demands, and other nonpatient care purposes.

These nonpatient care demands have distracted providers from the three primary uses for a medical record: (1) providing rapid access to recent information (about the patient's condition, laboratory tests, and drugs, for example); (2) ensuring continuity of care as responsibility for patient care shifts between different providers; and (3) as an audit tool to gauge the quality of medical care. These primary uses for medical records must not be sacrificed to facilitate secondary goals such as medical malpractice defense and billing.


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