The voices of the medical record

Abstract

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it ‘routine’ in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive ‘text’, it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.