Abstract
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.
Keywords
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Article info
Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: The author is solely responsible for writing this manuscript.
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Copyright
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
