Documenting dreams : patient-centered records versus practice-centered records

Abstract

This thesis explores how doctors and nurses use documents to share their knowledge within and across healthcare settings. In addressing this question I draw on a 15-month, multi-sited ethnographic study in several pediatric health care settings, following patients from primary care clinics, to emergency rooms, and in-patient units. The analysis focuses on the practices that go into documenting patients' histories and care, which include recordings on various on-line systems, preprinted forms, and whiteboards. By combining the previously distinct lenses of 1) knowing in practice, 2) time-space analysis of social interaction, and 3) communicative genre and genre systems, I suggest that doctors and nurses employ various types of document genres to manage, not only their distributed knowing about patients' care, but also their own movements across time-space. I outline a perspective on documents and knowing which attempts to highlight the role of human practice in how people use documents to coordinate their activities, share their capabilities, and get things done in complex distributed organizational work. The data suggest that doctors and nurses use medical documents as maps and itineraries to organize their distributed work practices. Doctors and nurses record patients' histories many times in different documents, with each document serving as a map and itinerary for a different constituency of people. Each of these documents is rarely used in isolation from other documents. Doctors and nurses constantly recombine the documents they use, which allows them to both appropriate documents from other settings into their local organization of work and build unique local combinations of documents.

(cont.) I introduce the concept of "re-localizing" to describe how doctors and nurses use documents to share their knowing within and across healthcare settings. Re-localization involves many healthcare professionals' parallel rewriting of a patient's history based on a recombination of each other's maps and itineraries and the patient's own accounts. By integrating the concrete case and the maps and itineraries based on those cases the notion of relocalization overcomes the dichotomy between the abstract and the situated, the local and global. Documents are not seen as mere vessels for abstract representations, but integral parts of distributed knowing within and across settings.