What follows isn't a researched history, just my personal impression of how medical records evolved. I'm old enough to have lived through these phases. I'm sure there are factual errors in my description, but this history serves its purpose and that is to illustrate why things are wrong and how. Please add and correct me where needed, that's what a wiki is for.
In what follows, I only describe the medical records in the context of a family physician aka general practitioner (GP) since that is the most typical use of medical records. Specialists use a smaller subset of it and often couple it with special purpose applications, confounding my arguments.
The olden days
Let's go back just 30-40 years and we find that people in general often had the same GP for life, or at least for 10 years or more. There was little need for any records, since the GP knew the patient's history by heart. The only documents he really needed to keep were lab reports, reports from specialist referrals and other external documents. Often these documents weren't filed in any kind of system at all. The first GP practice I worked in had nothing but a couple of stacks of documents in chronological order. If you needed to find a particular report for a patient, you had to know the approximate date it arrived, then go through the stack trying to find it. It was just that one set of stacks with documents for all patients together. No, it wasn't convenient, it wasn't very safe, but it almost worked since I had most information about the patient in my head, anyway.
But you can't take over a GP practice that doesn't have records unless you get to know the patients over an extended period, but that wasn't such a problem. Back then, you usually worked together for two years before the old GP left, so you could get to know the patients in the meanwhile, and they get to know you. That period allowed for the knowledge transfer.
The slightly less olden days
The first thing I did after taking over that practice was to institute records for my patients. They were fairly simple, just an envelope with the name on the outside and the notes and documents inside. These were then kept in open shelves alphabetically. On the outside of each envelope I wrote down the name, birthdate, important allergies and warnings, major issues, and insurance data. On A5 sized papers inside, I wrote a short note for each encounter, using abbreviations for most things like blood pressure, medication, etc. The average note was 2-3 lines of handwritten text. At about the same time, it became a requirement from the government to keep records, even though I would have done it anyway.
The motivation for keeping the records was threefold:
- To memorize data that is hard to remember. I can easily remember that a particular patient has a high blood pressure, but it's not so easy to remember when I first detected it and started treatment. Also, it's hard to remember exactly which medicines I've prescribed earlier and stopped again because they didn't work or had some undesirable side effect. I need notes for that.
- Due diligence. If I ever need to defend myself in court or otherwise, I need to have dates and specifics to defend myself.
- Transferring patients. If I hand over my practice to someone else, I can do it a lot easier and in a much shorter time if there is a written record. That written record replaces the two years apprenticeship period, in effect. Also, if a patient moves to another GP, I have a defined collection of documents and notes to give to the new GP.
It's important, very important, to realize that even with the availability of those documents and notes, the new GP will have to take some considerable time out to read through it all and see the patient a couple of times before he can build up the internal image of the patient he needs to proceed. All he gets through the records is a description of what has happened so far, not the reasoning behind it or the planning.
For instance, the new GP gets to know that I found high blood pressure and that I started a beta blocker, but not why. When I wrote down that note, I knew full well why, that's part of my training and I assumed that I would be the one continuing the contacts with the patient. Having another doctor take over the patient was an exceptional occurrence and the medical record wasn't designed for that, so it had no explicit mechanism to record reasoning and planning. If that is something you wanted to record, you just had to find a free form text expression for it and hope that your description didn't make unreasonable assumptions about the reader. Since there is no practical way of writing down the educational background against which you work with this patient, you must make the assumption that the reader largely has the same training and theories that you have, else your plan will be replaced by his. Often for the better, sometimes for the worse.
This changing of planning is ok, actually, especially since it only happens every couple of years and at such a change, overlooked problems often surface.
What has changed today is that the family physician isn't there anymore. The doctor tends to be totally interchangeable and the patient often sees a new one for every visit. But we still use a medical record that assumes that the doctor remembers the patient and only needs to read and record the hard to remember details such as dates and times. Which, by the way, explains why medical records are so date and time oriented.
In practice, what happens is that for each and every patient the doctor sees, he has to go through the process that used to take two years in the olden days, and at least a couple of hours in the less olden days. He has to go through everything that happened to the patient and try to deduce what the plan was and is, and where to go from here. He also has to deduce from indirect evidence if the previous doctors had the same kind of training as himself and reasoned similarly or differently. He can only deduce this from actual actions and try to figure out by scanning to and fro in the records, which data those doctors may have used to come to the conclusions they came to, or if they would indeed come to different conclusions than himself from the same data.
This, as you may imagine, is impossible. Having only the description of what has been done does not allow the reader to deduce why it was done and what, according to the implicit plan, would need to be done next, or even if it was a very good idea to begin with. There is no place in the medical records that allow for the inclusion of the master plan or even a reference to a master plan, and very little effort by anyone to try to describe such a plan in the notes. The result is that the master plan, if it ever existed, is created anew for each encounter and becomes totally inconsistent and largely useless.