Documentation: A Guide for Case Managers
Jackie Birmingham MS, RN, CMAC

$3.95 		Professional Case Management
April 2004 
Volume 9  Number 2
Pages 104 - 105
 
  PDF Version Available!

ABSTRACT
Outline

  • Brief History

  • The Integration of an Idea

  • Case Management: The “Snowplow” of Healthcare Delivery

  • The Medical Record as a Source Document

  • Purposes of the Medical Record

  • Web Sites:

    Brief History

    The concept of the “Medical Record” was reported in 1910 by the American College of Surgeons. There are known documents reporting medical care that date back centuries, but the idea of recording a total encounter or episode in one place is a relatively recent one.

    Ernest Codman, MD, from the American College of Surgeons, proposed the “end result system of hospital standardization.” Under this system, a hospital would track every patient it treated long enough to determine whether the treatment was effective and the “outcome” met expectations.

    The goal was to determine what made a treatment “successful” and to treat similar cases similarly. If the treatment was not effective, the hospital would then attempt to determine why, to improve the quality of care for future patients.

    In order to evaluate the end result of care long enough there had to be a systematic way of collecting information. In addition to collecting information, the medical information had to be organized in such a way that it could be tracked along the continuum and retrievable for future use.

    A “unit record” received extensive development and evaluation at the Presbyterian Hospital in New York where it was implemented in 1916.

    The Integration of an Idea

    The medical record can be seen as the building block to case management as we know it today. Case management has taken the idea of the “end result” and incorporated it as a matter of practice. One of the first initiatives that led to case management was utilization review. Professionals began to review medical ...

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