A Brief History of the Medical Record

Medical TranscriptionNo Comments

I have developed a love for the subject of history over the past few years. I was always intrigued by it as an undergraduate in university, but it took graduating and befriending a number of history professors at my alma mater to really gain a passion for it. You can’t help but find passion when those around you are passionate too! I’d like to share a little bit of that passion with you today in hopes that someone else is nerdy like me and finds things like cave paintings, Egyptian papyri, and legendary historic physicians fascinating. Today, we’re examining some points in history that have led to the medical record as we know it today. To the history!

Cave Paintings

cave paintings

(Source:smithsonian.com)

Throughout the world, cave paintings provide fascinating insight into prehistoric humans and their lives. Though animals play a large role in many of the paintings, researchers have found paintings that depict medical procedures and treatment of sick tribe members by tribal shamans or medicine men. You can check out some cave paintings with medical subject matter in the academic paper Prehistoric Pictography in North America of Medical Significance by Dale W. Ritter and Eric W. Ritter. Google actually has that section of the article available for viewing here. It’s unclear what the purpose of these cave paintings was, but it’s possible they were used to tell stories, much like a journal, or warn others of illness or ailments that have befallen their group.

Papyri

Papyri

(Source:britishmuseum.org)

The next evolution of significance included the written language. Did you know that some of the earliest “medical records” date all the way back to around 1600 BC? I read a very fascinating article called From Papyrus to the Electronic Tablet: A Brief History of the Clinical Medical Record with Lessons for the Digital Age by Richard F. Gillum, MD, MS from Howard University. Gillum discusses an Egyptian papyrus text on a surgery dating all the way back to 1600 BC. It appears the text was used for teaching purposes, indicating that the Egyptians grasped the importance of documentation for the education of others. Gillum also discusses Hippocrates of Cos (you know, the Hippocratic Oath), who lived from around 460 BC to 375 BC, and some of the medical writings associated with him. Though I’ve learned through additional research that most of the medical writings, including the Hippocratic Oath, that bear his name were likely not written by him, they still play an interesting role in the development of the medical record.  These texts, too, appear to have been used for teaching purposes.

Case Books

Case book

(Source:annals.org/)

Fast forward to the 17th century and the natural sciences were really taking off.  People were fascinated with not only dissecting cadavers, but also observing human anatomy and physiology and disease processes in live humans.  Physicians in Europe and elsewhere began keeping case books where they would record interesting cases for future reference. This trend seemed to catch on both across the pond and in the USA as it became more apparent that keeping accurate records on patients was essential to successful treatment of, teaching on, and prevention of diseases and ailments.

Modern Records

hanwritten note

(Source:bphata.com)

Let’s fast forward one more time to the 20th and 21st centuries. Early medical records as we know them today typically consisted of very abbreviated handwritten notes done by medical secretaries or assistants. There was an understanding that a more complete snapshot of a patient visit was necessary for treatment and research purposes, but doing that efficiently was a challenge.

Enter the profession of medical transcription. Doctors could dictate their entire encounters with patients, and medical transcriptionists would take those audio recordings and turn them into physical documents to be placed in the patients’ medical records. Each clinic and hospital kept their own medical records for each patient and, therefore, large transcription rooms appeared in the medical records departments.

Early on, typewriters were used by the medical transcriptionists to produce the documents and the noise, I can imagine, must have been deafening. This was well before the internet, so there was no “Googling” a term. They used hard copy references to research. The process was tedious and I can imagine that there were a lot of errors simply due to the fact that the technology wasn’t particularly advanced. (I also imagine that spelling was much better during that time because there wasn’t a reliance on spell checkers. Your brain was the spell checker. I digress.)

Computers made the process a little less tedious, but medical records were still stored in physical copy so even though your encounter may have been typed up on a computer, it was printed and stored in medical records rooms. The only way to transfer those documents between facilities was to go pick them up yourself or have them mailed to the other facility. If a doctor referred you to someone else, you’d often have to pick up your record from that clinic and take it with you to the next one.

As technology continued to improve and develop, paper records were replaced by Electronic Health Records (EHRs) and/or Electronic Medical Records (EMRs) and this is the system that is in use today. EHRs provide ready access to patients who want to review their records, as well as a faster and hassle-free (debatable) system to transfer the records between facilities. For example, after an unfortunate emergency room visit for me, I followed up with my primary care physician who was able to request my encounter record, lab results, and images from the hospital and had them within minutes so that he could provide the best possible care.

With the advent of EHRs, the role of medical transcriptionists has changed and continues to evolve, but they still can go hand-in-hand with EHRs to provide the most accurate medical records. We wrote a post about that very topic last year and if you’re interested in learning more about that, please feel free to pop over and read it.

There are a lot more complexities and much more history than what I provided here, but I hope it gives an interesting snapshot at how far we’ve come. Where are we going with medical records? Who knows! Perhaps in the future we’ll all have a chip embedded under our skin identifying who we are and containing our entire medical history. Whatever the future holds, we wouldn’t be able to get there without studying history.


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