Medical practitioners have been recording information about their patients' illnesses and treatments for hundreds of years. Before the 20th and 21st centuries, such records were kept mostly to help the practitioners retain and learn as much as possible from their own experience. Because there was little centralization or standardization of this information, it was difficult to organize and share the knowledge that resulted from studying many instances of similar cases.
By the early 1900s, medical record keeping was changing, along with many other aspects of health care. Medicine was more sophisticated, scientific, and successful in helping patients. Hospitals were increasingly becoming accepted as the conventional place for middle-class patients to go for care, and as a result, hospitals became more numerous and better organized. As hospitals grew larger and served more patients, the volume of patient records increased proportionately. With medical record keeping becoming more important and time consuming, it was most efficient and sensible to centralize it within the hospital. Recommendations by distinguished committees representing the medical profession also encouraged standardized record-keeping procedures.
By the 1920s, many hospitals in the United States had central libraries of patient information, with employees specifically hired to keep these records in good order. As time passed, their tasks became more complicated. The employees responsible for this work, who used to be called medical record librarians, eventually became differentiated into two basic professional categories: medical record administrators and medical record technicians. In 1953, the first formal training programs for medical record technicians started up in hospital schools and junior colleges.
In recent years, the digitilization of records, the growing importance of privacy and freedom of information issues, and the changing requirements of insurance carriers have all had major impacts on the field of medical records technology. These trends will undoubtedly continue to reshape the field in future years.
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