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August 15, 1966

Preciseness and Specificity for Medical Records

Author Affiliations

From the Division of Scientific Activities, American Medical Association, Chicago.

JAMA. 1966;197(7):569-571. doi:10.1001/jama.1966.03110070093023

Effective presentations of medical data are essential in the furtherance of modern medicine: for the continuing study and treatment of individual patients; as source material for statistical analysis of diseases and conditions; to reflect the contributions of preventive medicine, definitive treatment, and rehabilitation; to reveal the changing modes of diagnosis and treatment as influenced by the developments of clinical and fundamental research; for references in medical education and journalism; and in compliance with regulations of the US government and private agencies for information pertaining to claims for illnesses, injuries, and disability. The applications of computer technology in the handling of scientific data strike the imagination and emphasize the needs for thoughtful, authoritative, functional, and timely documentation. Accordingly, chiefs of hospital services, administrators, and accreditation boards strongly urge the perfection of medical records, first, for professional purposes and, second, to reflect the skills and excellence of diagnosis and the benefits of