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Medical Records, Electronic

  • By: Michael P. Pagano
  • In: Encyclopedia of Health Communication
  • Edited by: Teresa L. Thompson
  • Subject:Public Health Education & Health Promotion, Health Psychology, Health Communication

Since the opening of the first hospital in Pennsylvania in 1754, medical records have been a required communication medium in U.S. health care. Medical records are critical to the present and future care of patients and provide an opportunity for doctors, nurses, and other clinicians to document their interactions, examinations, assessments, tests, diagnoses, treatments, outcomes, and prognoses. For nearly 250 years, U.S. medical records were handwritten. However, to be shared with other providers or institutions the documents had to be photocopied and either mailed or faxed. Beginning in the mid-1990s, former presidents Bill Clinton and George W. Bush, and more recently President Barack Obama, pushed for a conversion in the communication format for medical records from a handwritten medium to an electronic one. These presidents ...

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