Practices of reading and writing: the constitutive role of the patient record in medical work

Abstract

This paper contributes to a reappraisal of the sociological significance of the medical record. Building upon re-evaluations of the notion of 'representation' in ethnomethodological and science and technology studies, it attempts to portray the medical record as an artefact which mediates the social relations that act and work through it. Through practices of reading and writing, it is argued, the medical record figures as a fundamental, constitutive element of medical practice. To address some of the dimensions that are involved, three case fragments are discussed. The way the medical record enters into the process of 'medical decision making' in the doctorpatient interaction, and into that interaction itself, is discussed first. Subsequently, some aspects of how the record mediates medical work as it is performed in the wards of a hospital are outlined. A third instance of its prominent role demonstrates how practices of reading and writing tend to produce particular renderings of patients' histories -including notions of how medical work is structured.

The clinical governance of the soul: ‘deep management’ and the self-regulating subject in integrated community mental health teams

“…In addition, there are some well-known arguments about the medical dominance found within health care such that medical staff are argued to have a controlling stake in the decision making, record keeping and governance of everyday patient care, even though much face to face contact is carried out by nurses in a 'handmaid' role (Berg, 1996;Berg & Bowker, 1997). This working practice has become sufficiently ritualised for some authors to call it the 'doctor-nurse game' (Stein, 1967;Snelgrove & Hughes, 2000).…”

Produzindo corpo, doença e tratamento no ambulatório: apresentação de casos e registro em prontuário

“…São colocados os resultados de outros exames e a nova prescrição. o prontuário, apesar de supostamente próximo da narrativa do paciente, não é uma transcrição direta da consulta, é uma reorganização, uma edição da conversa com o paciente (berg 1996;Cox 2001;Good 1993). por outro lado, nem tudo que está registrado é tema da consulta (freqüente-mente as anotações sobre diagnóstico e o estado das artérias são copiados de consultas anteriores, já que os dados do cateterismo não precisam e nem podem ser atualizados a cada nova ida ao médico).…”

Mapping Textually Mediated Information Practice in Clinical Midwifery Care

“…In particular, the clinical record has been analyzed extensively since Garfinkel's observation that "[r]eporting procedures, their results, and the uses of those results, are integral features of the same social orders they describe" (Garfinkel 1967, 192). Studies of documents in clinical settings have considered the ways that the clinical record contributes to medical work (Berg 1996), its role in the social construction of the patient or client (Berg and Bowker 1997, Bowler 1995, Macintyre 1978 and the constitution of the work of care providers (Berg and Bowker 1996), the narrative structure of operative reports (Pettinari 1988), and the accomplishment of accountability in radiological records (Yakel 2001). Researchers have studied the affordances of the paper medical record (Heath andLuff 1996, Fitzpatrick 2000) and have analyzed how this and other clinical records are used and the implications of these uses for the creation of electronic clinical documents (Gorman et al 2000, Reddy et al 2002.…”