Secondary analysis of a patient's medical record is a major source of data for research in prescribing. Its use for research is fraught with problems because this is not why it is created. However, the Audit Commission has also reported on poor documentation in clinical care¹, the record's primary role. What little is known about the creation of the medical record in general is mainly from the observational work of Berg². The aim of this study, part of a larger programme of work, was to explore the creation and use of prescribing documentation in medical notes from the perspective of the hospital doctors who were creating and using it.

Interviews were conducted with 28 hospital doctors (8 consultants, 5 registrars, 7 SHOs and 8 HOs) about appropriate prescribing, particularly those prescribing decisions that GPs would be expected to continue. This included discussion of documentation of prescribing decisions in the medical record. The interviews were audiotaped and either transcribed in full or converted into mp3 files. These data were analysed from an interpretivist perspective, assisted by NVivo and Atlas-ti software programmes.

The medical record was described as a narrative or story, fulfilling a dual role of enabling patient care and forming a record for critique by consultants or for litigation. There was a conflict facing prescribers between the creation of the notes and the use of the notes. On one hand, the 'hurried' environment of the ward gave very little time in which to document prescribing the way they would like to find it. On the other hand, the low 'signal to noise ratio' and the narrative nature of the notes made it very difficult to extract the 'right sort of information', unless the doctor had a clearly formulated question. Doctors often decided not to write the details of their decisions because they assumed that colleagues would know the relevant policy and fill in the gaps. This meant that the use of the notes then became an inferential process, described as akin to 'reading the minds of one's colleagues'. Assumptions had to be made all the time and although this was not seen as being ideal, it was recognised as being necessary.

The doctors were fully aware of the medical record as a flawed system, using many inferences to enable the smooth running of patient care. These results reinforce the findings of Berg that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge². Thus, what is not written may be just as relevant as what is. This has profound implications for those without that insider knowledge who are using medical notes for research purposes.

References

1 Audit Commission. Setting the Record Straight. A Review of Progress in Health Records Services. London: Audit Commission Publications, 1999.

2 Berg M. Practices of reading and writing: the constitutive role of the patient record in medical work. Soc Health Illness 1996; 18:499-524.