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The Evolution of the Electronic Health Record

Authors: Susan, Doyle-Lindrud;

The Evolution of the Electronic Health Record

Abstract

Medical record documentation of patient data has evolved during the past several years. Early patient medical records included brief, written case history reports maintained for teaching purposes. One such document obtained is a text from Egypt of 48 case reports that includes injuries, fractures, wounds, dislocations, and tumors that date back to 1600 BC. This document was written on papyrus text and acquired by Edwin Smith, an Egyptologist, in 1862 (Atta, 1999; Gillum, 2013). Case reports served as the patient record for many years, used only intermittently by physicians. By the 1880s, concerns regarding medical records as legal documents for insurance and malpractice cases encouraged administrators of hospitals to supervise record content (Gillum, 2013). By 1898, the patient record came to the bedside, moving from retrospective documentation to cases reported in actual time. Medical records resembled more of the present-day record with family history, patient habits, previous illnesses, present illness, physical examination, admission urine, blood analysis, progress notes, discharge diagnosis, and instructions (Gillum, 2013). .

Related Organizations
Keywords

Attitude of Health Personnel, Electronic Health Records, Humans, Computer Security

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Powered by OpenAIRE graph
Found an issue? Give us feedback
selected citations
These citations are derived from selected sources.
This is an alternative to the "Influence" indicator, which also reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Citations provided by BIP!
popularity
This indicator reflects the "current" impact/attention (the "hype") of an article in the research community at large, based on the underlying citation network.
BIP!Popularity provided by BIP!
influence
This indicator reflects the overall/total impact of an article in the research community at large, based on the underlying citation network (diachronically).
BIP!Influence provided by BIP!
impulse
This indicator reflects the initial momentum of an article directly after its publication, based on the underlying citation network.
BIP!Impulse provided by BIP!
29
Top 10%
Top 10%
Average
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