Case summaries: another method

Gary Fox describes a systematic and thorough method for recording clinical data in an electronic form. His system is concordant with our approach1 of grouping together logically linked information to “tell a story.” We are heartened that he also includes space for experiential text as an essential component of the case history.

Indeed, Fox's letter is a cogent reminder that the introduction of the electronic medical record (EMR), which holds great promise for standardizing data collection, archiving important information and facilitating the sharing of patient records among physicians and institutions, may nevertheless enforce the tendency to divorce the data from the patient. This concern is particularly prominent if the focus of an EMR is on collecting information that can be coded and categorized. In contrast, if electronic systems adopt the approach of explicitly reminding practitioners to record daily narratives, the EMR could increase the use of narrative medicine principles. Perhaps we should encourage technologically inclined house staff to “blog” rather than to “chart” information for their patients!