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Updated: May 29, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
[Documenting and describing. The epistemic function of psychiatric records, their archiving and reinterpretation into
1Institut für Medizingeschichte, Berlin. sophie.ledebur@charite.de
Abstract:
The paper attempts to reconstruct the writing of published case histories. Due to the establishment of a scientific classification system in psychiatry there were at the Charité several changes from the late 1870s onwards: (1) Not only was the documentation in the clinical records altered significantly, but also (2) the archive was reorganized into a double filing system and (3) the casuistic made a development from describing seldom or sensational cases into a mode which aimed to unfold psychiatric theory through 'typical cases'. Original medical records, the internal documentation of psychiatric observation, will be compared to their published version. Both, the narrative of a case study and the documentation in the clinical records reveal performative processes of observation and documentation.
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Purpose of Health Records II
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Archival Research
Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following: