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History of Medicine |

The Evolving Medical Record

Eugenia L. Siegler, MD
[+] Article and Author Information

From Weill Cornell Medical College, New York, New York.


Acknowledgment: This research took place during a sabbatical devoted to contemplation, conversation, and research about medical records. The author thanks James Gehrlich and Elizabeth Shepard for their resourcefulness and knowledge of the NYH's archives; Cary Reid for his insightful critique of an earlier draft of the manuscript; and Rosemary Stevens for her inspiration, mentoring, and support.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1788.

Requests for Single Reprints: Eugenia L. Siegler, MD, Division of Geriatrics and Gerontology, Weill Cornell Medical College, 525 East 68th Street, Box 39, New York, NY 10065; e-mail, els2006@med.cornell.edu.

Author Contributions: Conception and design: E.L. Siegler.

Analysis and interpretation of the data: E.L. Siegler.

Drafting of the article: E.L. Siegler.

Final approval of the article: E.L. Siegler.

Collection and assembly of data: E.L. Siegler.


Ann Intern Med. 2010;153(10):671-677. doi:10.7326/0003-4819-153-10-201011160-00012
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Form dictates content, and the manner of recordkeeping imposed on us probably influences how we think about patients. At The New York Hospital, physicians began to maintain permanent patient case records in the early 1800s. Originally proposed and valued as teaching cases for medical students, these freeform patient records varied in quality and often reflected not just the medical care of the time but also the personalities of the physicians composing them. At the end of the 19th century, the change from retrospective to real-time recording of cases and the imposition of a fixed chart structure through the use of forms dramatically reduced the narrative dimension of the hospital course. Gradually, physicians found ways to circumvent these restrictions. Changes in record format, designed to manage increasing volumes of data, and physicians' responses to those changes parallel some of the contemporary threats to documentation posed by the electronic health record.

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Appendix Figure 1.
1797 annual report of the Society of The New York Hospital.
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Figure 1.
Case and explanation from the first casebook, 1823.

Selected transcription is in the Appendix.

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Appendix Figure 2.
Cases from 1858.

Selected transcription is in the Appendix.

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Appendix Figure 3.
Case from 1879.

Selected transcription is in the Appendix.

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Figure 2.
Table of responses, case from 1899.

Selected transcription is in the Appendix.

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Appendix Figure 4.
First page of case from 1899.

Selected transcription is in the Appendix.

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Figure 3.
Discharge summary written on back of table from 1922.

Selected transcription is in the Appendix.

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Appendix Figure 5.
Physical examination, case from 1922.

Selected transcription is in the Appendix.

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