The Clinical Record in Medicine Part 1: Learning from Cases

History of Medicine15 May 1991The Clinical Record in Medicine Part 1: Learning from CasesStanley J. Reiser, MD, PhDStanley J. Reiser, MD, PhDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-902 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe clinical case record freezes in time that episode in life called illness. It is a story in which patient and family are the main characters, with the doctor serving a dual purpose as both biographer and part of the plot. The content of this biography varies greatly, reflecting its many purposes: to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions. In this essay, I discuss how clinical cases have shaped and reflected learning and action in medicine and how the document in which these cases are inscribed—the clinical record—has...References1. 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Google Scholar8. Cannon W. The case method of teaching systematic medicine. Boston Medical and Surgical Journal. 1900; 142:32. Google Scholar9. Painter F. Extending the influence of a hospital. The Modern Hospital. 1918;2:356. Google Scholar10. Washburn F. The Massachusetts General Hospital: Its Development. 1900-1935. Boston: Houghton, Mifflin; 1939:117. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: A version of this essay was presented at a symposium, "The Medical Journal: Past, Present, and Future," held in honor of Edward J. Huth, Editor of Annals of Internal Medicine, on 14 September 1989. Dr. Huth retired as Editor on 30 June 1990. The papers from the symposium will be published in a Festschrift in his honor.*The second part of the article focuses on twentieth century improvements in the content and purpose of the case record. It will appear in the 1 June 1991 issue. 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Barr, MD, MBAClinical methods: an historical perspectiveExperts and 'knowledge that counts': A study into the world of brain cancer diagnosisLes rapports de cas, vestiges du passé ?Clinical DocumentationClinical documentationMedical Record Reviews in Emergency Medicine: The Blessing and the CurseBarrier to Transition from Paper-Based to Computer-Based Patient Record: Analysis of Paper-Based Patient RecordsEmbodying the Patient: Records and Bodies in Early 20th-century US Medical PracticeHistorical Overview of a Psychiatric Clinical Information System: 'Peninsula Pathways'The Technologies of Time Measurement: Implications at the Bedside and the BenchStanley Joel Reiser, MD, MPA, PhDAn integrated electronic health record and information system for Australia?Use of Computer-based Records, Completeness of Documentation, and Appropriateness of Documented Clinical DecisionsMedical Records, Patient Outcome, and Peer Review in Eleventh-Century Arab MedicineGeriatric Rehabilitation: What Do Physicians Know about It and How Should They Use It?Educating Primary Care Physicians in Geriatric RehabilitationAttending to patients' stories: reframing the clinical task.Case Records and the Classification of DiseaseManuel Varela, MDKnowledge in Action 15 May 1991Volume 114, Issue 10Page: 902-907KeywordsElectronic medical recordsForecasting ePublished: 1 December 2008 Issue Published: 15 May 1991 Copyright & Permissions© 1991 American College of PhysiciansPDF downloadLoading ...