Communication in Medical Records

Abstract

Communication failures in the complex environment of hospital care affect the quality of care and occurrence of inadvertent harm. This study investigated doctors' written communication using a sample of medical records, specifically doctors' progress notes, and the frameworks of social identity and communication accommodation theories. These records include standardized and stylized language, and are intended to record assessment and treatment of patients according to known guidelines for practice. An interpretive analysis of the language and discourse in these records revealed that doctors used medical record entries both to express their specialty identity and to negotiate intergroup conflict. Nonaccommodation and interspecialty conflict sometimes took precedence over facilitation of patient treatment and management. Thus, intergroup communication in this context can constitute a serious threat to the quality of patient care.

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