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.