Clinical records: the medical writing from the patient's story to the medical narrative

Colomb Med (Cali). 2020 Mar 30;51(1):e4223. doi: 10.25100/cm.v51i1.4223.

Abstract

A historical follow-up on the medical diaries about the patient is made, from the Hippocratic texts to the appearance of the current canon of the clinical history formulated by Boerhaave in the seventeenth century, through the medieval consilia and the curationes and observationes of the Renaissance; and it is discussed how much the patient's story is present in those writings. It is postulated that the medical narrative that starts from adequately listening to the patient and his story, and adopts a literary workshop format, it is a pedagogical tool that contributes to comprehensive medical training, and offers the patient the opportunity to be treated in an empathic and humanized environment.

Se hace un seguimiento histórico a los escritos médicos sobre el paciente, desde los textos hipocráticos hasta la aparición del canon actual de historia clínica formulado por Boerhaave en el siglo XVII, pasando por los consilia medievales y las curationes y observationes del renacimiento; y se discute qué tanto el relato del paciente está presente en esos escritos. Se postula que la narrativa médica que parte de escuchar adecuadamente al paciente y su historia, y se trabaja en formato de taller literario, es una herramienta pedagógica que contribuye a la formación médica integral y ofrece la posibilidad de que el paciente pueda ser tratado en un medio empático y humanizado.

Keywords: Hippocrates; Medical writing; clinical case; consilia; health diary; humanization; medical records; narrative medicine; observatio; observation; patient centered care.

Publication types

  • Historical Article
  • Review

MeSH terms

  • History, 16th Century
  • History, 17th Century
  • History, 18th Century
  • History, 19th Century
  • History, 20th Century
  • History, 21st Century
  • History, Ancient
  • History, Medieval
  • Humans
  • Medical History Taking* / methods
  • Medical History Taking* / standards
  • Medical Records*
  • Medical Writing / history*
  • Narrative Medicine / history
  • Narrative Medicine / methods
  • Symptom Assessment / history
  • Symptom Assessment / methods