The evolution of the electronic health record

Area of Science:

• Medical history and documentation
• History of medicine
• Health informatics

Background:

• Early medical records were primarily brief case histories for teaching.
• Ancient Egyptian papyrus documents from 1600 BC detail various medical cases.
• Patient records were used intermittently by physicians for many years.

Purpose of the Study:

• To trace the historical evolution of patient medical record documentation.
• To highlight the transition from retrospective to real-time medical record keeping.

Main Methods:

• Historical analysis of medical record keeping practices.
• Review of early medical documentation, including ancient Egyptian papyri and 19th-century hospital records.

Main Results:

• Medical records originated as teaching tools, with early examples found in ancient Egypt.
• By the 1880s, legal and insurance concerns prompted increased supervision of medical record content.
• By 1898, patient records moved to the bedside, incorporating detailed patient information in real-time.

Conclusions:

• The evolution of medical records reflects changing societal needs, particularly regarding legal and insurance requirements.
• Modern medical records, including detailed patient histories and real-time data, are a result of significant historical development.