“A Meaningless Record”
Back in the day (1935), the Journal was called the “Bulletin of the Association of Record Librarians of North America.” That year it published a paper by Dorothy E. Fressle of St. Joseph’s Hospital in Chicago, originally presented at a meeting of the Records Library Association of Chicago and Cook County.
In that paper, titled “A Meaningless Record,” Fressle made a fresh and concise plea to record the “true story” of the patient’s encounter and promote that record’s use. She writes:
“Let me repeat that a good hospital record reflects a true story of the patient’s history and a clear picture of procedures actually carried out in the course of his treatment.
“Let us strive to keep our records practical and to stimulate our doctors and interns to study them. We should not let our departments become ‘lands of missed opportunities.’”
If Fressle’s plea sounds like common sense today, it is a good reminder of how far the patient record has come and how hard early HIM professionals worked to elevate and standardize it.
“He’s Doing Fine Now”
Harry Rhodes, a director of practice leadership at AHIMA, had a look at the type of records Fressle despaired of when he worked at Presbyterian Hospital in Oklahoma City. The hospital opened in 1917.
“We had families that would come and want to see grandpa and grandma’s records,” Rhodes says, “and they were expecting information like in the modern record.”
They didn’t find it.
Rhodes says, “There was stuff in there like, ‘I’ve known Bob for over twenty years; he’s always shoed my horses. His lovely wife’s here with him today, and we performed the procedure, and he’s doing fine now.’ And that was the record.”
We can thank Fressle and her pioneering colleagues that our records do not read the same.
Fressle’s article, attached here as a scan of the original publication, was published in September 1935 (volume 6, no. 4).