Doctors have always made notes about patients. By the 1800s doctors published their diagnoses and treatment records. However, there were no agreed standards for records or requirements to keep any.
Medical records became an important medical practice during the late 1800s. Treating large numbers of patients in hospitals and private practice relied on written records. In the early 20th century professional medical organisations pressured practitioners and hospitals to keep patient records.
Medical records were written on paper and kept in folders, but managing thousands of paper-based records became complex and expensive for hospitals during the 20th century. Tabulating machines sorted and managed patient records until the 1960s. Patient information was recorded onto key-punched cards which were sorted into groupings by the tabulating machine.
During the 1970s hospitals stored patient records electronically using computers. Computers stored and retrieved vast amounts of information at high speed and low cost. They became invaluable. However, there are concerns about the privacy and safety of electronic patient records.
J Howell, Technology in the hospital: transforming patient care in the early twentieth century (John Hopkins University Press, 1995)
S Teng Liaw, 'The Computer-Based Patient Record - An Historical Perspective,' Informatics in Healthcare Australia November, 2/5 (1993), pp 17-21
S J Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978)
S J Reiser, ‘Creating form out of mass: the development of the medical record’ in E Mendelsohn (ed.), Transformation and Tradition in the Sciences: Essays in Honor of I. Bernard Cohen (Cambridge: Cambridge University Press, 1984), pp 303-16