thesis
Towards formal medical reporting: An evaluation in endoscopy
- Publication date
- 4 October 1995
- Publisher
- For clinical practice, the patient record is the principal repository for
information concerning a patient's health care. For centuries, medical
notes were brief comments used by their author to trigger a fuller
recollection of his patients. In the late nineteenth century, physicians stalied
to document their findings and actions in personal ledgers. The concept
of a single record per patient was introduced in 1907. A proposal in the
I920s to enforce physicians to document sets of essential data met with
much resistance. Since then, the complexity and volume of medical data
increased, and specialization led to more health-care workers per patient.
As a result, the way data are recorded, processed, retrieved, and
communicated became ever more crucial in medical practice.
Neveliheless, the patient record underwent very little change. However,
it is now generally accepted that the traditional paper patient record can no
longer fulfill the expanding demands for information. As an alternative,
the computer-based patient record (CPR) increasingly gains interest. The
Institute of Medicine (USA) even considers the CPR to be essential for the
full maturation of the scientific basis of health care.