A Brief History of Patient Records with Dr. Kevin Johnson

Physicians creating formal documentation for a patient visit is a fairly recent activity in medicine, dating from antiquity through the Enlightenment.

This is a brief history of patient records narrated by Dr. Kevin B. Johnson, former Cornelius Vanderbilt Professor and Chair Department of Biomedical Informatics at Vanderbilt University Medical Center in Nashville, Tennessee.

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The practice of physicians creating formal documentation for a patient visit is a fairly recent activity in medicine.

In fact, at the beginning, even journaling was unheard of as far as we can tell.  In antiquity, Medical care was given based on patient-reported symptoms.

People were treated with rituals, prayers to drive out evil spirits, or surgery.  Even herbal potions came relatively late in our history.

As medical care became more commonplace in Greece and Egypt, some practitioners, inspired by astronomy, seemed to record private notes. 

But, for the most part, Medical care was more like getting a haircut is today.

Before the invention of paper and printing, it’s perhaps not a surprise that there is little evidence of journaling.

An Egyptian papyrus describing a surgical case around 1600 B.C. serves as our first record of recording case-level information. 

Case reports for didactic purposes became more commonplace during the era of the Hippocratic School in Greece.

The Enlightenment gave birth to the Natural Sciences, and with this, an interest in direct observation, anatomical dissection, and quantitative measurement.

Case reports become more prevalent during this time.

Two years after opening its doors., New York Hospital began keeping patient records in 1793.

Initially, the records were simple line items.

By the 1800s, case reports were common, especially for surgical or complex medical cases.  

By mid-century, doctors at academic medical centers commonly recorded notes in case logs and journals.  These notes might have been a sentence or two long initially.

Even Hospital records were very short—an entire month of a hospital stay could fit on one page!

Much changed in medicine following the First World War.  Antiseptic technique, surgical advances, blood transfusions, and X-rays were becoming commonplace.

By 1925, the length had increased threefold to six whole pages as more people got involved in patients’ care.

Hospitals developed specialization with more forms, more units, more tests, and more X-rays, leading to more documentation.

The modern typewriter led to an explosion of forms.

Professional medical societies evangelized. 

As the gap between hospital medicine and outpatient care narrowed, groups such as the American Medical Association, the American Association of Record Librarians, the Institute of Medicine, and others developed the hospital records we know today.

Evolving standards, research, regulation, EHRs, and information technologies continue to change what and how we capture patient records.

We are still very, very early in the maturation of medical documentation.

New technologies for data collection and analysis appear daily.

The role of caregivers is changing dramatically, including patients' participation in their care.

For all these reasons, we can expect exponential rates of change in both what gets recorded and how it gets done.

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