When your carefully scanned and compiled digital patient record is erased from your hard drive, you may find yourself nostalgic for the days of hard copy. How “hard”? Consider that the first medical records were recorded on clay tablets, using the wedge-shaped writing system known as cuneiform.
| Consider that the first medical records were recorded in clay tablets … |
Remember that these are just media. The message largely remains the same. Ethics of the Physician, a ninth century book by Ishaq bin Ali al Rahawi of northern Syria, includes the following recommendations regarding record keeping:
The physician, when entering a patient’s place to visit and treat, first calls for a blank white paper to write on, [and] after pondering the patient’s condition [records his evaluation and prescribes treatment]…. When he comes back, he sees what has changed or happened and records it in the same way, and so on in every visit. If he sees a sign that warns of worsening, he mentions that. If worsening does occur as he warned, he records it until the end of the illness and the patient encounter. If the patient recovers, he takes that record to keep as a resource or a reminder if another condition happens to that human. If the patient dies and someone raises the question of a mistake committed by the physician, the physician meets with the experienced people, he brings out the record to be examined by knowledgeable professionals in medicine. If the disease proves to be the same as was told, and the signs were the signs of the disease that are characteristic for it, and the drugs and management were satisfactory, the physician would be thanked and would leave. If not, he shall get what he deserves….
Take good care of the patient, pay close attention to the digital record and back it up, or you may also “get what you deserve.”
Michael Schulder, MD, is associate professor in the Department of Neurological Surgery and director of image-guided neurosurgery at UMDNJ-New Jersey Medical School.