The Evolving Medical Record
Type:
Article
Changes in record format, designed to manage increasing volumes of data, and physicians’ responses to those changes parallel some of the contemporary threats to documentation posed by the electronic health record. The following article, published in History of Medicine, summarizes the change from retrospective to real-time recording of medical cases, and the imposition of a fixed chart structure, beginning with the early creation of the medical record at The New York Hospital in 1797.