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The American Journal of Medicine Oct 2013A major transition is underway in documentation of patient-related data in clinical settings with rapidly accelerating adoption of the electronic health record and... (Review)
Review
A major transition is underway in documentation of patient-related data in clinical settings with rapidly accelerating adoption of the electronic health record and electronic medical record. This article examines the history of the development of medical records in the West in order to suggest lessons applicable to the current transition. The first documented major transition in the evolution of the clinical medical record occurred in antiquity, with the development of written case history reports for didactic purposes. Benefiting from Classical and Hellenistic models earlier than physicians in the West, medieval Islamic physicians continued the development of case histories for didactic use. A forerunner of modern medical records first appeared in Paris and Berlin by the early 19th century. Development of the clinical record in America was pioneered in the 19th century in major teaching hospitals. However, a clinical medical record useful for direct patient care in hospital and ambulatory settings was not developed until the 20th century. Several lessons are drawn from the 4000-year history of the medical record that may help physicians improve patient care in the digital age.
Topics: Electronic Health Records; History, 18th Century; History, 19th Century; History, 20th Century; History, 21st Century; History, Ancient; Medical Records
PubMed: 24054954
DOI: 10.1016/j.amjmed.2013.03.024 -
South Dakota Medicine : the Journal of... Jan 2014
Topics: Documentation; Electronic Health Records; Humans; Medical Records
PubMed: 24601065
DOI: No ID Found -
Bulletin of the American College of... Sep 1991In summary, the medical record not only helps a physician care for a patient, but may in the future also offer an indelible defense if the record is kept carefully and...
In summary, the medical record not only helps a physician care for a patient, but may in the future also offer an indelible defense if the record is kept carefully and meticulously. 'In the courtroom, medical records are witnesses whose memory never dies.'
Topics: Documentation; Liability, Legal; Malpractice; Medical Records; Physician's Role; United States
PubMed: 10113827
DOI: No ID Found -
Iyo Denshi To Seitai Kogaku. Japanese... Oct 1980
Review
Topics: Computers; Data Display; Humans; Information Systems; Medical Records; Medical Records Department, Hospital
PubMed: 7024599
DOI: No ID Found -
Methods of Information in Medicine Jun 1996Kay and Purves' proposed narratological model of the medical record is based on the familiar phenomenological insight that the perception of data is conditioned by the...
Kay and Purves' proposed narratological model of the medical record is based on the familiar phenomenological insight that the perception of data is conditioned by the conceptual framework of the perceiver. Unfortunately, unless handled very carefully, this approach will make the significance of a medical record unique to the person who constructed it and impermeable to outside scrutiny. However, when integrated into the analog-model of the medical record, the narratological model can be accommodated as the clinician-relative construction of a patient profile within the data that make up the medical record. Some implications for the construction of expert systems and competence analysis are indicated.
Topics: Data Collection; Humans; Medical History Taking; Medical Records; Medical Records Systems, Computerized; Medical Records, Problem-Oriented; Physician-Patient Relations; Quality Assurance, Health Care; Writing
PubMed: 8755378
DOI: No ID Found -
Bulletin of the School of Medicine... Oct 1962
Topics: Electronic Data Processing; Electronic Health Records; Humans; Medical Records
PubMed: 13991589
DOI: No ID Found -
Journal of the American Medical... May 2020Accurate documentation in the medical record is essential for quality care; extensive documentation is required for reimbursement. At times, these 2 imperatives... (Comparative Study)
Comparative Study
OBJECTIVES
Accurate documentation in the medical record is essential for quality care; extensive documentation is required for reimbursement. At times, these 2 imperatives conflict. We explored the concordance of information documented in the medical record with a gold standard measure.
MATERIALS AND METHODS
We compared 105 encounter notes to audio recordings covertly collected by unannounced standardized patients from 36 physicians, to identify discrepancies and estimate the reimbursement implications of billing the visit based on the note vs the care actually delivered.
RESULTS
There were 636 documentation errors, including 181 charted findings that did not take place, and 455 findings that were not charted. Ninety percent of notes contained at least 1 error. In 21 instances, the note justified a higher billing level than the gold standard audio recording, and in 4, it underrepresented the level of service (P = .005), resulting in 40 level 4 notes instead of the 23 justified based on the audio, a 74% inflated misrepresentation.
DISCUSSION
While one cannot generalize about specific error rates based on a relatively small sample of physicians exclusively within the Department of Veterans Affairs Health System, the magnitude of the findings raise fundamental concerns about the integrity of the current medical record documentation process as an actual representation of care, with implications for determining both quality and resource utilization.
CONCLUSION
The medical record should not be assumed to reflect care delivered. Furthermore, errors of commission-documentation of services not actually provided-may inflate estimates of resource utilization.
Topics: Adult; Aged; Documentation; Electronic Health Records; Female; Humans; Male; Medical Audit; Medical Errors; Medical Records; Middle Aged; Patient Simulation; Physicians; Quality of Health Care; United States; Veterans Health Services
PubMed: 32330258
DOI: 10.1093/jamia/ocaa027 -
Applied Clinical Informatics Feb 2017
Topics: Electronic Health Records; Humans; Medical Records, Problem-Oriented; Models, Theoretical; Natural Language Processing; Patient Admission; X-Rays
PubMed: 28197621
DOI: 10.4338/ACI-2016-04-IE-0054 -
Current Surgery 2005
Topics: Guidelines as Topic; Malpractice; Medical Records
PubMed: 16293505
DOI: 10.1016/j.cursur.2005.04.013 -
Joint Commission Perspectives. Joint... 1987
Topics: Documentation; Joint Commission on Accreditation of Healthcare Organizations; Medical Records; United States
PubMed: 10289804
DOI: No ID Found