Sunday, November 20, 2011


The Design of the Medical Record

The Design of the Medical Record
Part 1

The hospital medical record has existed since hospitals began. There are ancient Greek archives of Hippocrates' "Cult of Aesculapius" whose temples were the sites of the first recorded gathering places for care for the ill: primitive hospitals. Hospitals have evolved far in the past two millennia. The medical record evolved.

There was a revolution in hospital care that occurred in the sixth decade of the twentieth century, following WWII and the Korean War. Surgical care had progressed by leaps and in-patient medical care was progressing rapidly. The medical record evolved to serve as documentation and communication tool.

At the end of the sixties, the growth in hospital care was exponential. The entire scope of the medical record was carefully studied and intentionally designed. To a very great degree the medical record was standardized across America. The medical record as a tool of documentation and communication reached its pinnacle in the mid seventies.

The hospital medical record consisted of the following elements:
• Demographics
• Emergency room record
• History and Physical
• Physicians' progress notes
• Nursing notes
• Vital signs
• Consultation notes
• Procedure notes
• Laboratory reports
• Imaging reports
• Therapy reports
• Doctors' orders
• Discharge summary

A separate section of the chart held consent forms.

Each of the elements had its own tab in the binder. Other than the lab and imaging reports and the demographic face sheet the entire chart was hand-written. In some institutions, the doctors and nurses charted in the same progress note section. Sometimes the entire physician documentation, from emergency room, H&P, progress notes, and consultations were all in a single tab, written and stored chronologically sequentially.

What was most striking about the chart was the rigorous way that physicians and nurses documented their observations and their assessments. In particular, physicians delineated their diagnostic thought process and their therapeutic decision making. Everything was communicated and available in a well organized chart.

Granted, there was vast variation in compliance with this model. Physician poor handwriting was already a hackneyed joke. Some doctors just did not respect the value, beauty, and sanctity of the medical record.

The "problem oriented record", formulated by Dr. Weed, and adopted by the entire medical community in the late sixties was at the heart of the structure of the medical record. The chart contained a standardized PROBLEM LIST, with dates of onset and dates of resolution of each problem, with the problem described by the "highest degree of resolution". A problem initially listed as "abdominal pain" might later be resolved to "acute peritonitis" and later to "acute sigmoid diverticulitis with localized peri-colonic abscess". Each progress note referenced the problem list.

The progress notes were in the now famous SOAP format, summarizing the patient's subjective reporting, the doctors' (or nurses') objective observations as well as pertinent laboratory or imaging data, the professionals' assessment of each problem and a problem oriented plan.

The notes were sequential and clearly told the story of the hospitalization. The structure facilitated communication and decision making.

The initial "history and physical" had a structure that dates back to the early twentieth century. It was a careful record of the patients presenting complaint, a detailed history of the present problem, a summary of the past medical and surgical history, as well as family, and social data. A "review of systems" systematically reviewed the patients current reporting of any symptoms not clearly relevant to the presenting problem. Then came a structured comprehensive examination report, followed by a review of all the lab or ancillary data available at the time of admission. Next, the patient's condition was carefully analyzed in the assessment: the problem list was here generated. The preceding data was synthesized and a tentative series of diagnoses recorded. The thought process was delineated. The assessment was followed by the plan: how the doctor intended to proceed with treatment and diagnostics. The rationale was described.

Procedure notes and surgery notes had standardized structure and were included in the sequential flow of the chart.

At the conclusion of the hospitalization, a discharge summary was prepared, summarizing the entirety of the hospitalization.

In the design of a medical record for a new medium in a new millennium, the computerized medical records of the twenty-first century, it is incumbent on the creator to, at the least, maintain the working structures of the paper chart. Since no model has ever proven as valuable as the problem oriented record, it would seem obvious that the design of the electronic record should facilitate the production of an equally valuable record. Perhaps the high structure of database technology could even renew the values of the ideal record that have been lost, abandoned, or made sloppy by the past four decades of medical evolution. It is surely offensive and wrong for the system designer to impose models of data entry, recording, and retrieval that fit some model of program design, but that do not promote a medical record model that has been time honored by the medical profession.

Many forces in society, primarily government and financial institutions (third party payers) are placing tremendous pressure on the medical profession to conform to a model of medical practice that is foreign to our science and our traditions. It is fully acceptable for the medical record to serve as a tool for those forces if and only if the principles and values of the practice of medicine are not thereby compromised. Since the same forces are driving the institution of the electronic medical record, it is incumbent on the designers of that tool to honor our medical record.

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