The first health records were hand written by physicians. These records, even hospital and operative records, were brief, with little elaboration, but were generally regarded as adequate.
In 1913 the American College of Surgeons was founded. One of its main objectives was to improve the standards of surgical practice through the standardization of hospital records. Their 1918 survey found that only 1.6% of 5323 registered hospitals met the minimum standards which required that “accurate and complete case records be written for all patients and filed in an accessible manner”.
From the 1930’s through the 1950’s, medical stenographers were employed to take dictation from a physician in shorthand and then transcribe it into a final formatted document. The ability to take medical dictation in shorthand was a much valued quality. However, with the match of technology, more and more physicians began to use dictating machines to document patient care.
The machines used to record dictation, known as medical transcribers, can be traced back to Thomas Edison’s invention of the phonograph. President Warren Harding’s inaugural address was recorded in 1921, and through a crude relay system, it was dutifully transcribed by a typist and then sent to the major newspapers.
Computer technology is revolutionizing the dictation and transcription process, creating innovative advances in technology undreamed of just a few short years ago. Today, video images are able to be incorporated within the health record. Even as this is being written full-color photographs of pathology slides, prints of x-rays, MRI, and CAT scans, and even patient voiceprints are being graphically or digitally incorporated into the patient’s permanent health record.