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BACKGROUND: A BRIEF HISTORY OF MEDICAL RECORD KEEPING

The modern era of medical record keeping began in the late 19th and early 20th century. Medical records of that time period were largely unsystematic, as was medical education, which was unregulated and taught in privately owned medical schools. Written records were treated as no more than “notes to self,” of use and interest to individual practitioners only. In 1911, Richard Cabot, a Boston physician, published a book entitled, Differential Diagnosis: Presented Through an Analysis of 383 Cases,1 in which he demonstrated how individual records could be used to classify groups of patients according to the symptoms and signs they presented with, an early form of population medicine.

The next major innovation in written record keeping came in the late 1960s from Lawrence Weed, a physician and medical educator who was interested in ways of evaluating medical students’ clinical thinking skills.2 The Problem-Oriented Medical Record (POMR) was organized around the SOAP note (Subjective, Objective, Assessment, and Plan), a standardized method that could be used to assess students’ and, as it turned out, practicing physicians’ thought-processes and actions. Weed's innovation also paved the way for third parties (teachers, peers, and later insurance companies and the federal government) to use the written record to judge the accuracy, completeness, and quality of care delivered.

Another important shift in record keeping came in the early 1990s on the heels of the “digital revolution.” One major limitation of paper-based records was their physical storage and portability. Records were typically limited to a single location and facility, had to be retrieved by hand, and were placed in a holder on the exam room door (most of the time) by a medical assistant. Computers changed all that and allowed records to be accessed, shared, and archived instantaneously by individuals, institutions, researchers, and regulators without the traditional limitations of paper. By the early 1990s the Institute of Medicine recommended that all physicians should be using computers in their practice by the year 2000.3 By January of 2015, 83% of office-based physicians in the United States had adopted an electronic health record (EHR) in their offices (http://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php).

One final chapter in contemporary medical record keeping is the migration of computer-enabled health records from the back office, where they were used for coding and billing in addition to entering clinical notes and test results, to the exam room where they are used to document elements of the visit as it occurs. It is in the intersection of caring for patients (maintaining patient-centeredness) and documentation in the EHR (for coding, billing, and legal purposes) that is causing distraction and conflicts in clinician attention. Unfortunately, there are no national standards for where a computer and monitor should be placed for optimal patient-centered care, nor is there much guidance in how to handle the complexities introduced into the clinician–patient relationship by having an ...

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