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ARTICLE |

Preciseness and Specificity for Medical Records

Burgess L. Gordon, MD
JAMA. 1966;197(7):569-571. doi:10.1001/jama.1966.03110070093023.
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Effective presentations of medical data are essential in the furtherance of modern medicine: for the continuing study and treatment of individual patients; as source material for statistical analysis of diseases and conditions; to reflect the contributions of preventive medicine, definitive treatment, and rehabilitation; to reveal the changing modes of diagnosis and treatment as influenced by the developments of clinical and fundamental research; for references in medical education and journalism; and in compliance with regulations of the US government and private agencies for information pertaining to claims for illnesses, injuries, and disability. The applications of computer technology in the handling of scientific data strike the imagination and emphasize the needs for thoughtful, authoritative, functional, and timely documentation. Accordingly, chiefs of hospital services, administrators, and accreditation boards strongly urge the perfection of medical records, first, for professional purposes and, second, to reflect the skills and excellence of diagnosis and the benefits of

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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