Cooperative Epistemic Work in Medical Practice: An Analysis of Physicians’ Clinical Notes

Abstract

Abstract. We examine an important part of the medical record that has not been studied extensively: physicians' clinical notes. These notes constitute an explanatory medical narrative that documents the patient's illness trajectory by combining each physician's notes into a common text. Although several prior CSCW studies have addressed the role of the medical record in patient care, they have not dealt specifically with the role, structure, and content of these notes. In this article, we present a detailed analysis of a set of physicians' clinical notes recording the acute hospitalization and subsequent treatment of a patient with chronic heart disease. We show that clinical notes are highly structured and conventionalized texts that promote conciseness while at the same time allowing physicians to express themselves in a precise and nuanced way. Based on this analysis, we argue that physicians' clinical notes form the core of the medical record. They serve both as a 'tool for thinking' for the individual physician, enabling him or her to make sense of the patient's past history and current condition, and as a coordinative artifact used by physicians, nurses, and other health care professionals. We conclude by discussing the implications of this research for the design of Electronic Medical Record (EMR) systems.

Qualitative and quantitative approach to assess the potential for automating administrative tasks in general practice

“…Documentation of clinical encounters serves as a 'tool for thinking' for doctors and as an important means of coordination and communication. 40 Reading and writing clinical notes engage the medical professionals' critical faculties in a useful way. Allowing machines to take over would circumvent the way clinicians have been trained to document clinical encounters.…”

Automating Documentation: A Critical Perspective into the Role of Artificial Intelligence in Clinical Documentation

“…Recently some researchers have advocated for the application of AI systems to streamline and automate documentation tasks in healthcare [3,4], for example, by using natural language processing to dissect patient-doctor conversation and create notes [14]. However, incorporation of smart technologies into clinical documentation practices has been a controversial topic since research presents them as a web of complex work practices with institutional, social and situated dimensions [2].…”

“…This paper builds on an empirical investigation of the Primary Care service sector of the National Health Service (NHS) in England, and presents a detailed account of clinical documentation work, critical work that happens after a provider sees a patient. As Bansler et al [2] note: "clinical notes form the core of the medical record" (p.503). While some argue this work can be largely automated [3,4], in this paper we ask the key question: just because something can technically be automated, should it necessarily be?…”

The elephant in the record: On the multiplicity of data recording work

“…By doing so, we complement the research conducted on the variability of the "reading side" of data work. This latter variability, perhaps because of its ties to interpretation and sense-making, has been already acknowledged in the specialist literature and widely discussed in many studies from Garfinkle's work in 2008 to more recent ones: 14,15 different readers of the same record can depict to themselves different narratives 16 of the patient's illness trajectory, 17 also according to their knowledge. 18…”