Medical documentation arose as individual case reports written for teaching purposes. Documentation for patient care later occurred in physicians’ personal daybooks and only evolved into the individual patient record in the early 20th century. Dr. Lawrence Weed improved the utility of the patient record by introducing a problem-oriented/subject-object-assessment-plan structure and he and other innovators transformed the patient record into electronic form. Pediatricians built on these innovations to create a child health electronic health record (EHR) for primary care. An American Academy of Pediatrics task force formally specified the child-specific needs of the EHR, but much work remains to integrate the EHR into the pediatric primary care of the future.

医疗文件是为教学目的而编写的个别病例报告。病人护理文件后来出现在医生的个人日记本中，直到 20 世纪初才演变成个人病人记录。Lawrence Weed 博士通过引入面向问题/主体-客体-评估-计划结构改进了病历的实用性，他和其他创新者将病历转化为电子形式。儿科医生在这些创新的基础上创建了用于初级保健的儿童健康电子健康记录 (EHR)。美国儿科学会工作组正式指定了 EHR 的儿童特定需求，但要将 EHR 整合到未来的儿科初级保健中还有很多工作要做。