At the center of the galaxy: the integrative role of medical progress notes

Jørgen P. Bansler; Erling C. Havn; Troels Mønsted; Kjeld Schmidt

At the center of the galaxy: the integrative role of medical progress notes

Jørgen P. Bansler, Erling C. Havn, Troels Mønsted, Kjeld Schmidt

Datalogisk Institut

179 Citationer (Scopus)

Abstract

Studies of the medical record have generally taken the progress notes as just one entity among many. In contrast, we argue that progress notes are a coordinative artifact of a rather special kind that constitute the core of the medical record, in which physicians organize and summarize the immense amount of data that is available in the modern hospital environment. The study we report indicates that narrative plays a fundamental role in the way physicians document their findings and thoughts in the progress notes, because it allows them to not only record “facts” but also – by filtering, interpreting, organizing and qualifying information – to impose some order on events. Furthermore, we show how physicians use the progress notes to question available information, speculate about possible or plausible reasons for why something has happened, and suggest appropriate lines of action. This insight has important implications for the design of EMR systems.

Originalsprog	Engelsk
Publikationsdato	2013
Antal sider	4
Status	Udgivet - 2013
Begivenhed	4th International Workshop on Infrastructures for Healthcare: Action Research, Interventions, and Participatory Design - Tromsø, Norge Varighed: 13 jun. 2013 → 14 jun. 2013 Konferencens nummer: 4

Konference

Konference	4th International Workshop on Infrastructures for Healthcare
Nummer	4
Land/Område	Norge
By	Tromsø
Periode	13/06/2013 → 14/06/2013

Adgang til dokumentet

http://site.uit.no/infrahealth/files/2013/06/Bansler_3.pdf

Citationsformater

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AU - Bansler, Jørgen P.

AU - Havn, Erling C.

AU - Mønsted, Troels

AU - Schmidt, Kjeld

N1 - Conference code: 4

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N2 - Studies of the medical record have generally taken the progress notes as just one entity among many. In contrast, we argue that progress notes are a coordinative artifact of a rather special kind that constitute the core of the medical record, in which physicians organize and summarize the immense amount of data that is available in the modern hospital environment. The study we report indicates that narrative plays a fundamental role in the way physicians document their findings and thoughts in the progress notes, because it allows them to not only record “facts” but also – by filtering, interpreting, organizing and qualifying information – to impose some order on events. Furthermore, we show how physicians use the progress notes to question available information, speculate about possible or plausible reasons for why something has happened, and suggest appropriate lines of action. This insight has important implications for the design of EMR systems.

AB - Studies of the medical record have generally taken the progress notes as just one entity among many. In contrast, we argue that progress notes are a coordinative artifact of a rather special kind that constitute the core of the medical record, in which physicians organize and summarize the immense amount of data that is available in the modern hospital environment. The study we report indicates that narrative plays a fundamental role in the way physicians document their findings and thoughts in the progress notes, because it allows them to not only record “facts” but also – by filtering, interpreting, organizing and qualifying information – to impose some order on events. Furthermore, we show how physicians use the progress notes to question available information, speculate about possible or plausible reasons for why something has happened, and suggest appropriate lines of action. This insight has important implications for the design of EMR systems.

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ER -