|dc.description.abstract||This thesis investigates how different health professionals record the history of the presenting complaint of patients with suspected acute myocardial infarction admitted to a rural hospital.
Different health professionals, each with their own ways of working and communicating, co-operate in diverse teams that ideally have more to offer the patient than individual professionals working alone. This includes the taking and recording of the patient’s history. This account should not be regarded as merely a way of copying a component of a clinical encounter, but as part of a sophisticated tool to guide and organise patient care.
This is a case study conducted by a participant observer. A range of qualitative research analysis methods for document analysis are used to analyse what is written in patients’ clinical records by general practitioners, ambulance officers, hospital nurses, and rural hospital doctors, about their presenting complaint.
Of 347 patients admitted to the hospital in 2011 who had a Troponin I blood test ordered, the clinical characteristics recorded of 50 are compared, and 10 of these are selected for more in-depth analysis. The 10 records are analysed in terms of style, vocabulary, abbreviations, what gets recorded, what gets repeated, what gets added, what gets deleted, and what gets modified. Three of the 10 records are analysed to explore how the individual records are constructed.
The clinical record emerges an incremental, multi-authored, multi-layered, intertextual account, being co-produced by a range of health providers, using information from a variety of sources. The different health providers, at different stages, and using their different voices, interact to record the history of the presenting complaint.
In addition, the clinical record can be seen as a way of telling the patient’s story, like a novel where the central narrative is explored from the perspectives of different characters or commentators. The record is a carefully constructed document, whose chief purpose is to develop a shared understanding of the patient’s progress and the care that needs to be provided.
Good documentation is equated with good care. It is important for practising clinicians to understand how the clinical record is constructed, as an organised interdisciplinary process, and how it is used in care. Furthermore, with a move to electronic health records, it is essential that those responsible for their introduction have a similar understanding of the nature of clinical records.||