Towards formal medical reporting: An evaluation in endoscopy

For clinical practice, the patient record is the principal repository for information concerning a patient's health care. For centuries, medical notes were brief comments used by their author to trigger a fuller recollection of his patients. In the late nineteenth century, physicians stalied to document their findings and actions in personal ledgers. The concept of a single record per patient was introduced in 1907. A proposal in the I920s to enforce physicians to document sets of essential data met with much resistance. Since then, the complexity and volume of medical data increased, and specialization led to more health-care workers per patient. As a result, the way data are recorded, processed, retrieved, and communicated became ever more crucial in medical practice. Neveliheless, the patient record underwent very little change. However, it is now generally accepted that the traditional paper patient record can no longer fulfill the expanding demands for information. As an alternative, the computer-based patient record (CPR) increasingly gains interest. The Institute of Medicine (USA) even considers the CPR to be essential for the full maturation of the scientific basis of health care.