Medical records: use and abuse

摘要

In the beginning the patient told the doctor a secret. And, behold, the doctor kept the secret in his head until he died or forgot it. Later on, the patient told the doctor a secret, and the doctor wrote an aide mémoire for himself in cryptic handwriting, abbreviations (or in Latin), and destroyed it when he retired. Later again, the patient told the doctor a secret and the doctor wrote it out clearly in a record folder shared with his or her partners and a nurse or two, which the receptionist saw but couldn't talk about outside on pain of losing her job, and which followed the patient about like a bloodhound for the rest of their life. And now, the patient tells the doctor a secret and the doctor can do one of two things: she can type it into a practice computer system, soon, under the government's Information Strategy for the Modern NHS 1998–2005 to be amalgamated into a national electronic health record, or — she can keep the secret in her head until she dies or forgets it.