Nielsen2014

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Nielsen2014
BibType ARTICLE
Key Nielsen2014
Author(s) Søren Beck Nielsen
Title Medical record keeping as interactional accomplishment
Editor(s)
Tag(s) Medical EMCA
Publisher
Year 2014
Language
City
Month
Journal Pragmatics and Society
Volume 5
Number 2
Pages 221–242
URL Link
DOI 10.1075/ps.5.2.03nie
ISBN
Organization
Institution
School
Type
Edition
Series
Howpublished
Book title
Chapter

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Abstract

Medical records are documents of tremendous social importance. They have been the subject of much medical and sociological research, in particular regarding validity, accessibility and readability. This paper uses Conversation Analysis to add an aspect to the understanding of medical records that has been missing so far, namely how medical records are produced as interactional accomplishments; specifically, how hospital staff members during meetings conversationally negotiate and reach conclusions, treatment recommendations, and other types of consequential decisions. The process involves four steps: assessing patients, interpreting implications, drawing conclusions, and dictating conclusions on tape. The key finding is that participants throughout the process orient towards a need for consensus, whilst at the same time acknowledging the doctors’ interactional leading roles. This insight can enhance our understanding of medical records in hospital settings as constructed and negotiated realities.

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