[Formalizing observation: The emergence of the modern patient record exemplified by Berlin and Paris medicine, 1725-1830].

Abstract

The paper focuses on the material basis of the development of modern clinical documentation. With the examples of Berlin and Paris medicine, it analyzes the various ways of recording clinical data in the 18th century, from where they came, and how they were introduced into bedside observations. Particular interest is given to the interrelation between administrative techniques (registration, book-keeping etc.) and the practices of medical recording developed within the hospitals. Comparing Berlin and Paris makes it possible to work out the differences in writing cultures and to consider the local interdependencies. With this approach it can be demonstrated that the "patient record" was already established as a patient related recording system in the form of loose files in the early 19th century.