Unit 1: History of Medical Records Administration

  • Unit 1: History of Medical Records Administration: Overview, Objectives, Learning Outcomes, Unit Prerequisites, Pre-Unit Preparatory Material, and Table of Topics.

    • Early focus in hospitals was on statistical summaries of case abstracts.
    • The health record is important for the patient and healthcare provider, providing an organized case history invaluable for proper assessment.
    • Main Topics:
    • Introduction
    • Evolution
    • Medical Records in Mesopotamia
    • Egyptian Medical Records
    • Ancient Greek and Roman Medical Records
    • Medical Records in the Digital Age
    • The Arabs
    • The Swedes
    • The Paper Based Patient Record
    • Comparison period from 1968 to 2000 year
    • Conclusion
    • A patient medical record is required to note patient information and communicate health problem, diagnosis, and treatment.
    • The development of automated systems for dealing with health care data parallels the need for data to comply with reimbursement requirements.
    • Early Focus in Hospitals:
    • The Flexner report was the first formal statement made about the function and contents of the medical record. 1910
    • Mayo clinic in USA had begun to record the diagnoses for every admitted patient 3 years earlier before Flexner report published in 1910.
    • The Flexner report also encouraged physicians to keep a patient-oriented medical record.
    • Hospital-accrediting bodies in the 1940s began to insist on accurate, well-organized medical records as a condition for accreditation.
    • Hospitals required to abstract certain information from the medical record and submit it to national data centers.
    • Discharge abstracts contain:
    • Demographic information
    • Admission and discharge diagnoses
    • Length of stay
    • Major procedures performed
    • National centers produce statistical summaries of case abstracts, allowing hospitals to compare their profile.
    • Computer-Based Hospital Information Systems (HISS) - Emerged in the late 1960s; primarily for communication and charge capture.
    • Collected orders from nursing stations and routed them, identified chargeable services, and gave clinicians access to lab results.
    • Major purpose was to capture charges.
    • Retained the content for long after a patient's discharge.
    • Lawrence Weed's Problem-Oriented Medical Record (POMR) in 1969 influenced medical thinking.
    • Emphasized organizing medical records by medical problem, linking diagnostic and therapeutic plans to a specific problem.
    • Morris Collen: Early pioneer in using hospital systems for laboratory results and preventive care.
    • Use of computers to screen for early warning signs of illness was a basic tenet of HMOs.
    • Early university hospital systems (HELP, CCC, Registries System) added clinical data and decision-support functionality.
    • Medical records have evolved since ancient civilizations in Egypt, Greece, and Rome.
    • Ancient Mesopotamian records, clay tablets written in cuneiform documented patient history and Spells, astrology, and astronomy.
    • Egyptian scribes transcribed medical information on papyrus scrolls + Egyptian records reveal that medicine was being practiced in its many forms, from surgery to general medicine and even dentistry
    • Greek and Roman medical records - Creation of systematic recording systems + Logical and scientific train of thought with descriptions of a patient's mental and physical history + gods are still mentioned, illness was viewed as a result of the gods' displeasure
    • Greek and Roman medical records were transcribed on parchment, which is prone to disintegrating.

  • Medical Records in the Digital Age:

    • Arabs kept and developed knowledge of Greek medicine (Islamic Medicine).
    • Arabs introduced the concept of hospitals and keeping written records of patients and their medical treatment.
    • Students kept records, edited by doctors and used for future treatment.
    • Swedes (Carl Linnaeus and Nils Rosén von Rosenstein):
    • Linné classified nature; Rosén von Rosenstein focused on medical record writing (De historiis morborum rite consignandis).
    • Rosén von Rosenstein introduced the taking of careful notes of his patients, their symptoms, diagnosis and treatment as well as their social condition.
    • The first formal medical record system in Sweden developed in 1752 (Seraphim Hospital).
    • Paper-Based Patient Record:
    • Records written for physician memory support and use by other clinicians.
    • Nurses write daily notes; physicians make notes at certain time points.
    • Documentation for legal reasons.
    • Different names: patient record, health record, case sheet, case history.
    • Contents: patient identity, visit reason, history, physical examination, symptoms, assessment, treatment, time points, treatment result, discharge letter (epikrisis).
    • At the doctor's visit, the physician checks for symptoms.
    • For patients admitted to the hospital, the patient record contains daily notes of the status and progress of the treatment + The discharge letter should contain a summary of the whole healthcare period, with instructions on how the patient should be taken care of after discharge from the hospital.
    • Source-oriented patient record: Divided based on the information source (physician, nurse, lab).
    • Problem Oriented Medical Record (POMR) and SOAP model.
    • SOAP: Subjective, Objective, Assessment, Plan.
    • Paper record analysis is difficult due to the need for scanning and OCR techniques.
    • Greek and Latin in Patient Records:
    • Terminology derived from Greek and Arabic, translated to Latin.
    • Swedification of medical terms in Swedish.
    • Medical Record Development:
    • Workload increase led to machines (typewriter, dictaphones, computers).
    • Maintenance records for inpatient, outpatient, and emergency room encounters.
    • Shift from paper to electronic records.
      Comparison Period (1968-2000):