July 8, 2013

The Challenge to the Medical Record

Author Affiliations
  • 1Department of Nuclear Cardiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
  • 2Department of Medicine and Radiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire

Copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2013;173(13):1171-1172. doi:10.1001/jamainternmed.2013.976

Observe, record, tabulate, communicate.

Sir William Osler

Thirty years ago, not long after I began teaching first- and second-year medical students how to take patient medical histories and perform physical examinations, it occurred to me that I was trying to teach them how to write. I came to see that taking a medical history, performing a physical examination, reviewing ancillary data like electrocardiograms, laboratory results, and imaging studies, and organizing this information into a coherent and useful document that could be recorded with a pen on paper—the now antique tools that were used at the time—is in fact a specialized form of the writing process.

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