The Electronic Medical Record, Lawrence Weed, and the Quality of Clinical Documentation

Physicians began writing disease descriptions in early antiquity but it wasn’t until the end of the nineteenth century that they started keeping records intended to assist in individual patient care.1 In the early twentieth century, it became customary to organize bedside patient records into sections dedicated to different disease features, such as symptoms, physical findings and test results. Eventually, attempts were made to adopt a standard report format, but the content and organization of what had become the patient chart were still found to be inadequate by many.