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February 23, 1957


Author Affiliations

Smithfield, Va.

Member, Committee on Medicolegal Problems, American Medical Association, and Member, Virginia State Bar.

JAMA. 1957;163(8):657-659. doi:10.1001/jama.1957.82970430007019

The written record that a physician maintains of his treatment of a patient frequently mirrors the quality of the care given the patient. It also may reflect the professional competence of the physician himself. The fact that written records should be maintained need not here be belabored. Their general importance to the physician in his continuing study of the patient's condition and in evaluating and reevaluating the correctness of the initial diagnosis and the treatment being applied is obvious. It is to the patient's benefit also that the written record be a complete one to serve as a constant reminder to the attending physician of the progress of his case so that danger signals can be promptly detected and changes made, if indicated, in methods of treatment. Leaving from consideration these aspects of the written record, however, let us relate the record and its contents specifically to the matter of