The Evolution of Medical Records

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Medical records have been around for many years. Even as far back as the sixteenth century. Today they are known as electronic health records and are a vital part of taking care of patients as well as using the information for demographic and research purposes. In the past records were not kept very well, if at all. This paper will trace the evolution of medical records to what we use today. This paper will explore how records were kept in the sixteenth century all the way to how they are kept today. The importance of these records will also be explored as well as the methods that were developed. In the sixteenth century medical records were kept mainly as observations of what the physician learned about a patient or the human body and not so much as a record of the patient’s health and wellbeing. Two men, Simon Foreman and his protégé Richard Napier, where astrologers in the late 1500’s and early 1600’s. Forman started the record keeping and after his death Napier took over. They treated patients based on what was going on in the stars as opposed to what was going on in their body. Of course, this was by no means helpful to the patients. Also, by all accounts neither Napier nor Foreman had a very good reputation. Although, somehow they still had people, a lot people who consulted them when they were sick. Why that is, is never explained. However, they did do something that no one else had done before, they recorded the symptoms of their patients. Both of these men were prolific recorders. Between them they saw as many as 50,000 people. These records or casebooks as they are known had, “At least 90% of the questions related to matters of health and disease. The remainder included questions about marriage, career prospects, persons... ... middle of paper ... ...n a standardized form, as a result physicians could not compare notes easily (Olivia Banner. (2012).). Now that has all changed with the use of computers. Records are easier to find, share, and enter data. Medical records are now referred to as patient health records. This because the records deal with the patient has a whole and not just what the physician has observed or done. These records are now a legal document and owned by the physician and his or her practice. Medical records as you can see are very important not just for the physician but also for the patient. Though out history they evolved into not just a record of observations to prove the physician right or to use it as a way of collecting payment but as a way to track a patient’s health and wellbeing. Medical records are very important and will continue to be very important in the days and years ahead.

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