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PHYSICIAN'S OFFICE RECORDS

Traditionally, physician's office records were for a single physician treating a group of long-term patients. The record served to remind the physician of the patient's medical history and to record the patient's treatment for billing purposes. With the advent of specialty and subspecialty care, private physicians began to see more limited-term patients, increasing the number of separate individuals in the physician's practice and reducing the number of times a physician sees a patient. Although physicians keep records in a manner that assumes that they know each patient personally, many of the patients are strangers to the physician. Add to this the enormous increase in available therapies, the high probability that the patient will be cared for by more than one physician, and the increase in multiple physician clinics, and the traditional physician office record is hopelessly out of date.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) provides detailed requirements for the maintenance of medical records in the hospital, but there is no comparable set of standards for physicians' private office records. Consequently there is a tremendous variation in the quality of physicians' office records. As with hospital medical records, private office record-keeping styles evolved during a period that demanded less comprehensive record keeping than is necessary today. Physicians should use a standard medical record format such as the problem-oriented medical record for all their medical records. (See the section in the Bibliography on problem-oriented medical records for a detailed discussion of this record format.)



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