Thursday, November 19, 2009

A 1930 Medical Record

I was recently in my hometown of New Martinsville visiting my dad, a retired family physician. When I arrived he had waiting for me a copy of one of my grandfather's medical records from the 1930s. My grandfather, Dr. Albert Coffield, practiced rural medicine in Wetzel County, West Virginia from 1911 until his death in 1936.

My dad told me the following story about the medical record.
My dad was a doctor who practiced out of his house on Coffield Ridge in Wetzel County. After my dad died in 1936 our mother sold the household furnishing and his office equipment. I was 12 years old when he died and my older brother was a first year student at West Virginia University. Since my mother wasn't employed she decided to move us to Morgantown where the University was so that my older brother could continue his college education. As a way to continue the family income she rented rooms to college students - many who came to the University from Wetzel County.

Included in the sale of the household and office furnishing was a wooden credenza with metal alphabetized slides. Behind some of the slides were some old medical records that were left in the credenza.

Thirty years later a lady who was a patient of mine brought the wooden credenza to me and told me that she had bought the credenza at the auction of my family's household items in 1936. She told me that she thought I would appreciate having it.
Here are photos of the medical record of a patient from 1934. The medical record format is simple yet complete. It contains all the important demographic and clinical information - including the patient statement, habits, family history, past history, physician examination and diagnosis. On the back is additional space for notes and a drawing of the internal organs that I suspect was meant to be used with the patient for education and instruction. It even has a built in billing record section that even the change:healthcare crowd would love.

What can these photos tell us about the current health care reform debate. Compare these photos of a medical record from 1934 to those that cost .73 cents today. Could today's physician and his or her patient get "meaningful use" out of this record?


A close up of the billing section for the change:healthcare gang.


12 comments:

rlbates said...

My kind of record! I love the diagrams. I often include sketches in my office notes.

e-Patient Dave said...

Y'know what's great about this? (Aside from the delicious historical perspective.)

I'm no expert but I betcha this was fully up to speed with the state of the art in business technology. :-)

I'm eager to see that day again!

(And if anyone knows otherwise, I'm all ears.)

e-Patient Dave said...

And, btw, what a WONDERFUL historic family gift! You could start a museum!

Get a Model T, too. An authentic one.

Dr. Rob said...

I like the fact that you blacked out the name for HIPAA.

Looking at it does make me pine for a simpler life.

Bob Coffield said...

Dr. Rob,
Yes, I decided it was best to black out the name. The privacy "back story" on this is the fact that a physicians wife sold off all her deceased husband's medical equipment and files. The individual who bought the medical record file kept the medical records for 30 years and then returned them to the physician's son.

Steven Butler said...

This actually doesn't look much different from most of the records that I review from Primary Care Physicians on a daily basis today. I am actually disappointed to see that record keeping hasn't improved in over 70 years.

Anonymous said...

Why does the date appear to be 1984?

medrecgal said...

Fascinating...much different than the EMR I stare at all day. The only upside to the EMR is that you can actually read it without being a handwriting interpreter. I seem to remember from volunteering at a hospital many years ago before the advent of EMRs that many people who entered information into medical records had atrocious handwriting. (Not just the doctors, but many others too.) This example's not too bad; I can actually read it and figure out what happened in that encounter.

Bob Coffield said...

Anonymous, I also thought it read 1984 - but after closer look it was 1934. The 3 just appears to be closed in. Again, an example of poor handwriting mentioned in the prior comment.

Bryan said...

Thanks for sharing this, Bob. I love seeing this stuff. I'm wondering if something like this could be archived on the web somewhere.

Sharon said...

This is really a wonderful family story and a very touching deed from the individual who returned the medical records.

Tracy, Status Now

Clarity Health Journal said...
This comment has been removed by a blog administrator.