Full Answer Section

• Ancient Beginnings: The practice of recording medical information dates back thousands of years. Ancient Egyptian papyri (e.g., Ebers Papyrus from 1550 BCE) and Sumerian clay tablets from 2400 BCE show early forms of medical documentation, primarily lists of prescriptions, treatments, and observations (CKEditor, n.d.).
• Early Modern Era: By the 1700s and 1800s, standardized systems for daily patient observation and treatment histories emerged in hospitals in Europe and the U.S. (CKEditor, n.d.).
• 20th Century – Paper Records Dominance: For much of the 20th century, the bedrock of HIM was the paper medical record. These records were:
  • Physical Files: Housed in folders, divided into sections, and stored in vast filing cabinets within medical records departments.
  • Handwritten: Notes, orders, and results were predominantly handwritten, leading to issues with legibility and standardization.
  • Single Copy: Typically, only one physical copy existed, making sharing and access difficult and prone to delays.
  • Limited Access: Access was restricted to those physically present at the record’s location, hindering care coordination across different providers or institutions.