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Recommended Readings
Cutler P: Problem Solving in Clinical Medicine: From Data to Diagnosis, ed 3. Baltimore Williams & Wilkins Co, 1998. This entire book is a medical gem. I recommend reading it cover to cover toward the end of the second year of medical school to prepare for intense clinical activity. Although Cutler advocates a more detailed and lengthy data base than is generally practical, his material on records and presentation is as wise and helpful as the rest of the book. The second edition (1985) of this book contained fewer cases but was much more extensive in discussing records and presentation.
Donnelly WJ: Righting the medical record: Transforming chronicle into story. JAMA 260:823–825, 1988. This is a readable and important article that makes a strong case for including “the voice of the patient” in the medical narrative. As information technology advances, clear thinking like Donnelly’s is needed to provide a defense against those who would have us produce illness narratives using only sparse, limited language that can be processed even by unsophisticated computer systems.
Orient JM: Sapira’s Art and Science of Bedside Diagnosis, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2000. This book magnificently lives up to its title. It is useful to the medical student, but will remain a good friend throughout one’s career. It presents an uncompromisingly Hippocratic view of our profession and of patient-physician relationships. The sections on recordkeeping are detailed to the extreme. Few physicians will live up to the standards in this book, but the vision of excellence it portrays is a wonderful guide for those striving to be the best.
References
Council on Scientific Affairs, American Medical Association: Users and uses of patient records: Report of the Council on Scientific Affairs. Arch Fam Med 2:678–681, 1993.
Cutler P: Problem Solving in Clinical Medicine: From Data to Diagnosis, ed 2. Baltimore, Williams & Wilkins Co, 1985, 199.
Donnelly WJ: Righting the medical record: Transforming chronicle into story. JAMA 260:823–825, 1988.
Donnelly WJ, Brauner DJ: Why SOAP is bad for the medical record. Arch Intern Med 152:481–484, 1992.
Osheroff JA, Forsythe DE, Buchanan BG, Bankowitz RA, Blumenfeld BH, Miller RA: Physicians’ information needs: Analysis of questions posed during clinical teaching. Ann Intern Med 114:576–581, 1991.
Sigurdsson G: The medical record in general practice: Where art and science meet. Scand J Prim Health Care 2:113–116, 1984.
Tang PC, Fafchamps D, Shortliffe EH: Traditional medical records as a source of clinical data in the outpatient setting. Proc Annu Symp Comput Appl Med Care 575–579, 1994.
Weed LL: Medical records that guide and teach. N Engl J Med 278:593–657, 1968.
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© 2002 Kluwer Academic Publishers
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Chop, W.M. (2002). Recordkeeping and Presentation. In: Mengel, M.B., Holleman, W.L., Fields, S.A. (eds) Fundamentals of Clinical Practice. Springer, Boston, MA. https://doi.org/10.1007/0-306-47565-0_12
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DOI: https://doi.org/10.1007/0-306-47565-0_12
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