The days of doctors scratching illegible notes in charts fated to hide in obscure files never read by another soul is long gone. Over the last two decades, paper charts have nearly disappeared as the evolution of the electronic health record (EHR) has come to dominate the healthcare environment not only in the US, but globally. The health record performs multiple types of labor. It serves to facilitate communication in medical care or research; it is a legal document and a record to justify billing. A new diagnosis and billing code must make its first entry into the medical record accompanied by the signature of a clinician authorized to determine this diagnosis. After this initial entry, non-professional personnel may then use this diagnosis for any of the above purposes (communication, billing, legal). This blog post explores how developments like the patient portal of the EHR create new opportunities for interpretation, (read more...)