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History of patient charting

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By the early nineteenth century, a predecessor of contemporary medical records had arisen in Paris and Berlin. In the nineteenth century, prominent teaching hospitals in the United States pioneered the development of the clinical record.

The earliest patient records, dating back to “antiquity,” were created for instructional and educational purposes at least 4,000 years ago. Written case history reports were found to have been developed for didactic purposes by medieval physicians. The forerunner of modern medical records, researchers have discovered, “first appeared in Paris and Berlin by the early 19th century.” It was not until the 20th century that “a clinical medical record useful for direct patient care in hospital and ambulatory settings” was developed and used regularly.

By the early 20th century, healthcare providers were charting patient visit notes and medical history to be used in the treatment of those patients. According to an article published by Rasmussen College, “Documentation became wildly popular and was used throughout the nation after healthcare providers realized that they were better able to treat patients with complete and accurate medical history. Health records were soon recognized as being critical to the safety and quality of the patient experience.”

Patient charting was standardized by the American College of Surgeons (ACOS), which established the American Association of Record Librarians. Today the association is known as the American Health Information Management Association (AHIMA). Paper patient charts were handwritten and kept in files on specially designed shelves until the mid to late 20th century, when new technology was being developed.

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Throughout the late 20th century, patient charting began to be moved into electronic systems. The electronic health record (EHR) was originally developed for hospitals and universities, but by the 1980s, more focused efforts were made to increase the use of EHR among medical practices. While manual patient charting and filing was vulnerable to errors, the Centers for Medicare & Medicaid Services (CMS) recognized that the EHR “can improve patient care by:

• Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
• Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
• Reducing medical error by improving the accuracy and clarity of medical records.”

Patient charting has advanced significantly in the past 4,000 years. In the 21st century, patient data can be accessed and shared seamlessly among providers caring for the patient, through EHRs. The primary care physician now has the ability to coordinate care electronically and accurately, ensuring the highest quality outcomes.

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