Case records

“Despite this bulk, significant data are often left out, most notably a well-drawn narrative account of the illness itself. The usual clinical account . . . screens out the patient’s experiences and the doctor’s view of them. Indeed, the narrative part of the record often seems to remain an aide-memoire for the physician writing it rather than a clarifying note to others who will read it. . . . Concerns about self-protection inevitably change the character of the record and endanger its credibility. Other concerns, even when their purpose is to serve the medical needs of patients, can have a similar effect. For example, when the clinical record is written with a view to establishing claims for third-party billing, justifying the appropriateness of hospital admissions for review boards, or gearing diagnostic conclusions toward diagnostic-related group requirements, its truthfulness can be compromised” (Reiser III, 984).