Eric S. Marks, MD
To the Editor: My understanding of Dr. Burnum's article (1) is that most inadequacies of the medical record are interpreted as caused by pressures from society and regulatory agencies. I believe that with a few notable exceptions, the primary problem is a lack of writing skills by physicians and other health care providers.
The medical chart is intended to record accurately the diagnostic logic used in the care of the patient including observation, description, interpretation, and verification. Even though diagnosis-related groups and related criteria guidelines are relatively strict, the rational approach to diagnosis and treatment does not require a "flood"
Eric S. Marks. Poor Medical Records. Ann Intern Med. 1989;110:1037. doi: 10.7326/0003-4819-110-12-1037_1
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Published: Ann Intern Med. 1989;110(12):1037.
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