The Use of Evidentiality in Physicians’ Progress Notes

Abstract

The practice of medicine involves obtaining, evaluating and analyzing information drawn from a variety of sources; thus physicians assess and act upon information that varies in terms of both reliability and the extent to which it may be directly perceived. In the hospital setting, physicians’ progress notes provide a record of this process that serves as a primary means of communication between treaters who are not co-present with one another; accordingly, in order to permit independent evaluation of the information they contain, physicians have developed a repertoire of linguistic devices to express differing attitudes towards the information that their notes convey. In this article, through the microanalysis of a pediatric resident’s note, I demonstrate how physicians use evidential markers, including the passive voice and agentless constructions, to construct frameworks of credibility and responsibility that both underlie and enable medical work. These grammatical devices permit the physician-reader to weigh for himself or herself the evidence which supports the conclusions reached.

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