Division of Geriatrics and Gerontology, Weill Cornell Medical College, 525 East 68th Street, Box 39, New York, NY 10065, USA.
Ann Intern Med. 2010 Nov 16;153(10):671-7. doi: 10.7326/0003-4819-153-10-201011160-00012.
Form dictates content, and the manner of recordkeeping imposed on us probably influences how we think about patients. At The New York Hospital, physicians began to maintain permanent patient case records in the early 1800s. Originally proposed and valued as teaching cases for medical students, these freeform patient records varied in quality and often reflected not just the medical care of the time but also the personalities of the physicians composing them. At the end of the 19th century, the change from retrospective to real-time recording of cases and the imposition of a fixed chart structure through the use of forms dramatically reduced the narrative dimension of the hospital course. Gradually, physicians found ways to circumvent these restrictions. Changes in record format, designed to manage increasing volumes of data, and physicians' responses to those changes parallel some of the contemporary threats to documentation posed by the electronic health record.
形式决定内容，我们所采用的记录方式可能会影响我们对患者的思考方式。早在 19 世纪初，纽约医院的医生们就开始为患者建立永久性的病历。这些病历最初是作为医学生的教学案例而提出并受到重视的，它们的质量参差不齐，不仅反映了当时的医疗护理水平，还反映了撰写病历的医生的个性。在 19 世纪末，病历记录从回顾性转变为实时记录，通过使用表格强制采用固定的图表结构，大大减少了医院病程的叙述维度。渐渐地，医生们找到了规避这些限制的方法。记录格式的变化旨在管理不断增加的数据量，而医生们对这些变化的反应与电子病历给文档记录带来的一些当代威胁有些相似。
