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July 1960

Record of Medical History: A Device to Promote Better Medical Records

Author Affiliations

New York

From the Department of Medicine, New York Hospital—Cornell Medical Center.

Arch Intern Med. 1960;106(1):22-34. doi:10.1001/archinte.1960.03820010024006

The Problem of Inadequate Medical Records  Medical schools, hospitals, The American College of Physicians, The American College of Surgeons, and other agencies are seriously concerned with the inadequacy of hospital records and with the inadequacy of the records of medical care as they exist in the offices of physicians.Every physician was taught and should know that the most important part of any medical examination is an accurate and detailed record of all of the events in the patient's life that relate to his health. Every able physician knows that one of the chief causes of error in diagnosis and in treatment is the failure to elicit a full and complete medical history. Furthermore, every medical student is taught how to elicit and record a first class medical history. Students are advised to record, as nearly as possible, the exact words of the patient when describing the symptoms of illness.