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A Review Of The History Of Different Medical Recordformats, And Their Effects On Medical Education
Benjamin Mohseni SARAVI, MD,a Azar KABIRZADEH, MD,b Aggdass KABIRZADEH, MD,c
aB.sc in Medical Records, The Head of Informative Experts Council, bM.sc in Medical Records, A Member of University Scientific Board of Mazandaran Medical Sciences University, cB.sc in Medical Records, IRAN
In all the sciences, the documents which had already been recorded make the foundation of educational curriculum. In other words, study of past events can be a way to indicate what had happened before, and what must be done in the future. All researchers need to study the information and research results of the others in their own research activities. As it is recommended to use definite writing formats for the essays in order to facilitate studying and presenting research results, it is also suggested to create kind of a format for patients' records so as to facilitate studying medical records and findings gained through each patient’s treatment.
Since 1960, the idea of a format for paper-records and document registration has been put forward. Since for the time being paper-records are also used to register documents, researchers are struggling hard to find other formats which can pave the way for re-finding and using medical records. Having a definite style for records can create a framework to register the observations, too. A format called "Problem Oriented Medical Records" has basically developed to increase the medical education level and to present approaches to use patients’ records in order to develop favorable education. Other formals such as “Source Oriented Medical Records” or “Time Oriented Medical Records” are also included among traditional formats.
Using these two styles, however, pose more problems than using "POMR" format, since they have their special writing patterns of records and documents. In addition to the recording and documentation directions, there has been advice for all treating team of how to record documents. The ward nurses, for instance, will record the results of clinical care-taking in a “nurse-observatory sheet”. Thus, nurse education will be facilitated this way. The existence of a record format can create a primary framework for the records, and will indicate what must be recorded and what must not.
When the content of records includes enough, accurate, orderly and precise data then will be profitable for educational use. They must be produced in a form so that they can be usable in the future.
The author will introduce different records formats as well as their effects on continuous medical education in this essay.Keywords: Medical records, history of medicine, medical educationTurkiye Klinikleri J Med Ethics 2006, 14:159-162
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