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New Perspectives in Medical Records pp 103–113Cite as

Medical Record for Clinicians: Present and Future Vision

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Part of the book series: TELe-Health ((TEHE))

Abstract

This chapter is about the state of the art for the creation of a good and sharable in medical record. This kind of record should take into account the inception point; that means that it has to start with the first encounter with the patient, where his or her history has to be properly taken. To achieve such a result, the record is supposed to start with the prerequisites that come out from ethical, epistemological and logical consideration; it should not be in conflict with the data acquirement and should not create a medical record that aimed only to economise (that is the base of the critics where the medical record has been described as a disruptive innovation). That is a type of innovation that creates new networks and new organisational cultures involving new players” with a potential improvement of health, displacing “older systems and ways of doing things. This seems more a business and bureaucratic decision, rather than one guided by science.

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Notes

  1. 1.

    Statement of the EU Ministers of Health, Brussels May 22, 2003.

  2. 2.

    There are other formal definitions of eHealth; a fairly recent is: “eHealth means using digital tools and services for health. eHealth covers the interaction between patients and health-service providers, institution-to-institution transmission of data, or peer-to-peer communication between patients and/or health professionals. Examples include health information networks, electronic health records, telemedicine services, wearable and portable personal health systems and many other information and communication technology (ICT)-based tools assisting disease prevention, diagnosis, treatment and follow up” (EU Action Plan 2010–2020).

  3. 3.

    Crossing point between perceived needs and requirements of the man and the citizen, “requests” for care and capacity of medical/healthcare personnel to “meet the needs” as stated on the definition of eHealth.

  4. 4.

    Bonora N, Gardellini A, Moretto D, Pettinato A: Failure model & critical Effect Analysis of the Patient Summary NCP38, Val di Setta District, Bologna, Italy. Thesis of the High Course on eHealth of Bologna University (director: Prof AV Gaddi, advisor: Prof F Bonsanto, 2010). The results of this study have highlighted numerous serious problems and the risk of clinical errors. The results were transmitted to the leaders of regional health. We have no further information.

  5. 5.

    Personally, I hope for a holistic revolution that defines a new paradigm to understand the man, of conceptual synthesis and not based (only or mostly) on complicated analysis of large amount of data.

  6. 6.

    To the patient, to the environment in which he lives, to his wellness, and to the care of his family and other people.

  7. 7.

    The concept of inception point is essential for the scientific research as to the clinical reasoning on one individual, to prognostic aim (P, the main thing), therapy (T, useful to improve the prognosis) and, finally, diagnosis (D, often necessary to formulate P and T; but sometimes used only for taxonomic and disciplinary purposes.

  8. 8.

    Tri-Shear Project (6th EU Framework Programme, not financed; see Ref. [1] for details).

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Authors and Affiliations

  1. Società Italiana di telemedicina e eHealth, Messina, Italy

    Antonio Vittorino Gaddi

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Correspondence to Antonio Vittorino Gaddi .

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  1. Ospedali Riuniti Marche Nord, Pesaro, Italy

    Giovanni Rinaldi

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Gaddi, A.V. (2017). Medical Record for Clinicians: Present and Future Vision. In: Rinaldi, G. (eds) New Perspectives in Medical Records. TELe-Health. Springer, Cham. https://doi.org/10.1007/978-3-319-28661-7_8

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  • DOI: https://doi.org/10.1007/978-3-319-28661-7_8

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