The standardisation of hospital medical records / report of the sub-committee.

  • Great Britain. Standing Medical Advisory Committee
Date:
1965
Catalogue details

Licence: Public Domain Mark

Credit: The standardisation of hospital medical records / report of the sub-committee. Source: Wellcome Collection.

    8/68 (page 2)
    isation we found that our work called for consideration of much wider aspects of medical records. We were forced to give thought to the first principles of medical records: their purpose and function. Perhaps because the first principles seem obvious we found that little had been written, at least in this country, on the philosophy of medical records but coinciding with our term of office we noticed some interesting discussions, particularly Mr. H. A. F. Dudley’s paper read to the conference of the Association of Medical Records Officers at their conference in 1962(1), and an article by Mr. Bryan N. Brooke in the Lancet(). A scientific session at the B.M.A. conference at Oxford in 1963 was devoted to medica] records(+). We hope that this represents a growing interest in this relatively underdeveloped field of study and that it will lead to consideration of the purpose of medical records being taken further than we felt able to do within our limited terms. 7. Medical records are as old as medicine itself and some of the ancient records contain most admirably succinct and workmanlike accounts of con- ditions and their treatment. Their nature emphasises the basic character of medical records at all times: running records which are essential to the manage- ment of the patient’s treatment. But the records of the past also tell us a great deal about the development of medicine and illustrate most clearly how current practices have developed from past experience. This leads us to ask if medical records should be more than running records; whether they should also be shaped with the future use of current records specifically in mind. We agreed that the answer to this would have a fundamental influence on our approach to standardisation. 8. There is already a good deal of retrospective research into medical records. Individual doctors look back into records of their own making as part of the process of personal development which is an essential feature of the practice of medicine; or they may carry out some line of clinical research in which they are interested; or they may simply pursue an idea which though hardly formal research may nevertheless be valuable. On a wider scale medical records are used by workers following a particular line of clinical research, and by epidemiologists and workers in social medicine. All this work is however fragmentary and limited in scope. At present the only morbidity survey for general hospitals undertaken on a national scale is the Hospital In-Patient Enquiry, but this cannot claim to be comprehensive since the only morbidity data analysed is the discharge diagnosis and the enquiry covers only ten per cent of discharges and deaths. It is tempting to consider the unique opportunity offered by the National Health Service for a national system of data analysis on a far more detailed and comprehensive scale. Clearly our present methods of maintaining medical records are quite inadequate for such a project. Even on the present limited scale, research into medical records is far from easy. Individ- ual doctors are helped by memories of their own past cases and the extraordinary ability of medical records officers to retrieve documents on the flimsiest of (1) Dudley, H. A. F., 1962. The Medical Record. London, Association of Medical Records Officers Ltd., p. 580. (2) Brooke, B. N., 1962, Lancet, i, 738 (3) 1963, Brit. med. J., ii, 309.