Medical records and their keepers

In the course of collecting materials, it seems inevitable that those charged with maintaining records become part of the historical documentation.

img0044.jpgI recently stumbled across two items that document the changes in managing medical records and the role their keepers play in the larger health care delivery system. The first document is a typed page summarizing key points regarding the use of medical records in court. The text is taken from the 1941 Manual for Medical Records Librarians by Edna K. Huffman. It notes that “the position of the medical records librarian is one of especial trust” and “it is her duty to ascertain that the record is properly completed.” The responsibility of the medical record librarian is to protect the “chief value of a medical record… an unbiased statement inasmuch as the doctors, interns, nurses, and others concerned in making the record at the time of the patient’s hospitalization have no interest in any subsequent litigation.”

img0046.jpgAlmost forty years later, the medical records librarian has been replaced by the medical records manager. In a 1980 article from the UMHC Monitor (a former publication of the University of Minnesota Hospital and Clinics) the activities of the medical records department are highlighted to introduce others to their important function within the health delivery system. The director at the time, John Dennis, explained “Management of information is the business we’re in. We deal with the whole life-cycle of recorded information, from the creation of the information to distribution and maintenance.” Accredited record technicians (ARTs) and Registered Record Administrators (RRAs) “ensure that all record components are accounted for” including the coding and abstracting of records for electronic storage. The message of the article concludes with stating “record and information management goes beyond the basic ‘record’ and deals with their generation and use. It is a powerful institutional tool contributing to quality patient care and increased revenue.” Indeed.