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Conflicts over Control and Use of Medical Records at the New York Hospital before the Standardization Movement

Published online by Cambridge University Press:  01 January 2021

Eugenia L. Siegler  and
Andrew B. Cohen
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Extract

Medical records contain important clues about the history of medicine. These documents, which ostensibly describe the course of a patient's illness, are “unique constructions that allow us to observe the social and technical structure of contemporary healing.” As such, the 21st-century hospital medical record reflects the many components of inpatient care: medical interventions, billing, legal documentation, research, and education. It is comprised of a wide array of elements: professionals' notes; vital signs and other descriptive information; laboratory data and test results; demographic information; orders, charges, diagnostic and treatment codes; and other utilization data. It is well understood that many people share and need this information. Current controversies over records involve not control, but computerization, security, and accessibility. Although health professionals offer input, decisions about hospital medical records have been considered largely an administrative responsibility.

Type
Independent
Information
Journal of Law, Medicine & Ethics , Volume 39 , Issue 4 , Winter 2011 , pp. 640 - 648
Copyright
Copyright © American Society of Law, Medicine and Ethics 2011

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