Outlines • No. 2 • 2003
Carsten S. Østerlund Documenting Practices The indexical centering of medical records This paper explores how organizational members use documents to share their knowledge within and across work settings. I suggest that organizational studies of Vignette: Two patients, two doctors, two
distributed knowledge sharing and information systems would greatly benefi t from the linguistic analysis of Around four oʼclock on a February afternoon in communicative practices. Specifi cally, the paper high- Kiltham Hospital an infant boy, Dylan, lies in a lights the notion of indexical centering as formulated by small transparent plastic crib. Two doctors and the linguistic anthropologist William Hanks and demon- a medical student are simultaneously leaning strates its analytical power in studying documenting as a over Dylan, three stethoscopes pressed to his communicative practice. Drawing on a 15-month, multi-sited ethnographic study in several pediatric healthcare chest listening, eyes turned to the ceiling. The settings, the paper focuses on how two doctors compose medical student and two doctors, an intern and and use two medical histories found in two distinct me- a senior resident, fi nish their exam and turn to dical information systems. The analysis suggests that the the other infant in the room, Anna. Similar to doctors use documents to index the temporal, spatial, Dylan, she has been admitted for bronchiolitis. and participatory dimensions of their knowledge sharing. Both infants spent several weeks in the hos- They do so by indexing, on the one hand, the participants, times and places for their communicative practices and, pital, fi rst in the intensive care unit (ICU) and on the other hand, the participants, times and places of then transferred to their current beds in a regu- their general care practices. The indexical analysis allows lar pediatric department, 10 East. The intern, us to perceive documents, as more than mere vessels for Marc, a newly minted doctor in his fi rst year knowledge transfer among organizational members, but of medical residency, and the senior resident, as an integrated part of how people structure their work Elisabeth, in the fourth year of her residency, practices and situate their knowledge sharing in complex turn to Annaʼs mother sitting weary-looking distributed organizational settings.
beside Annaʼs crib.
Elisabeth says, "We know this has been a long ordeal for all of you; but we think Anna will be ready to go home tomorrow or the day after." Marc continues: "I will put the discharge papers together and the nurse will help you get ready to go home." 40878_outlines 2003 nr2 43 3/31/04, 14:50:40 Carsten S. Østerlund • Documenting Practices
After they have assured Annaʼs mother that documents it in the Senior Notes. These differ- her baby will be fi ne, Marc, Elisabeth, and the ences are particularly apparent during morning medical student all head for the doctorsʼ con- rounds when interns and senior residents can ference room in this medical unit. The medical be seen equipped with starkly different types of student grabs a clean Progress Note sheet at the documents, each describing the same patients nursing station. Behind the glass walls, known in slightly different formats. The interns shuf- as the aquarium, Marc, the intern, and Eliza- fl e through long printouts from their HOSO beth, the senior resident, each fi nd a computer online system which lists all the patients seen terminal. Marc logs on to the "House Offi cer by the team in alphabetic order including im- Sign-Out" (HOSO), an on-line system. Elisa- portant information on problems, medications, beth logs into the senior resident note system. and tests. In contrast, the senior resident on the They each start updating their notes on Dylan, team holds a printout neatly stapled together Anna and the other patients they have seen with small concise narratives summarizing since 7:00am. Marc will never read the senior individual patient cases.
residentʼs notes and vice-versa. Neither of these One can observe comparable document- documents go into the offi cial medical record ing practices among the nurses and other nor do Marc and Elisabethʼs supervisors access physicians involved in Dylan and Annaʼs those two information systems to evaluate them care. Each healthcare provider typically or compensate them for their work.
maintains multiple records of patient care, many of which they do not share with other Information systems and
collaborators. Such observations irk the medical informatics community which has worked for the past three decades to develop At fi rst glance it seems counterintuitive if not universal patient-centered records – placing counterproductive that the senior resident and all relevant information about a patientʼs the intern would not use the same informa- history at doctorsʼ and nursesʼ fi ngertips. tion system to document their care. Elisabeth Researchers in the American Medical Infor- spends most of the day in close collaboration matics Associationʼs (AMIA) Work Group with Marc and three other interns. They gather for People and Organizational Issues (poi- for rounds in the morning, see new patients [email protected]) regularly have list server together, go to radiology rounds, have noon discussions on the topic of failure rates in conferences, and share meal breaks. In the after- healthcare information systems (IS). Though noon the senior works closely with one or more impossible to verify, many quote 80% fail- interns in the teamʼs conference room writing ure rates for the implementation of medical notes or going to patient rooms for joint inter- information systems. The exact percent- viewing and patient examination. As in Dylan age aside, today one fi nds that individual and Annaʼs cases, it is not uncommon to see a settings, departments, and sub-disciplines medical student, an intern, and a senior resident within healthcare facilities have implemented all bent over the same child, each with their their own information systems. For instance, stethoscopes on the young patientʼs chest.
emergency departments will often have one These groups obviously share practices, electronic record system, the Intensive Care they regard themselves as teams, yet they do Unit (ICU) another, outpatient care a third, not share the same document genres. Marc and nurses (in some hospitals) yet another documents Dylan and Annaʼs histories in the nurse-use-only online record system; rarely HOSO, and Elisabeth, the senior resident, do these systems communicate.
40878_outlines 2003 nr2 44 3/31/04, 14:50:41 Outlines • No. 2 • 2003
The problem speaks to a larger theoret ical knowledge as local, context dependent, and question of how people use documents and in- emerging from interactions and practices in formation systems to coordinate their activities particular contexts. This would be the know- and knowledge about patients within and across ledge involved in the practice of medicine settings. More generally, the question becomes: within specifi c healthcare settings, given how do organizations best support viable in- changing collaborators and unfolding care formation systems that sustain their membersʼ for particular patients. One should note that capabilities to operate effectively both within "situated" typically gets depicted as "local" or and across temporally and geographically dis- context bound. The dichotomy creates a divide tributed settings? In recent years, this issue has between abstract transferable knowledge and received increased attention in the management situated non-transferable knowledge.
and organization studies literature with the pro- From this perspective, situated knowledge liferation of distributed work organizations, cannot be shared across contexts. Situated virtual teams, and various information tech- knowledge becomes not only embedded in a nologies attempting to support organizational context but bound to a context (Dreier, 1999). structures and the sharing of knowledge among In other words, if one remains locked in this its members.
abstract/situated dichotomy it becomes impos- A special issue of Organization Science on sible to develop a situated perspective that takes knowledge illustrates this debate (Grandori et into account the sharing of situated knowledge al, 2002) and its general push to differentiate across contexts in complex distributed organ- types of knowledge to account for the sharing izational settings. In the following discussion I of knowledge in various organizational set- will use "abstract versus situated" as shorthand tings. As Orlikowski (2002) points out, this for this broader dichotomy.
body of literature differentiates at least two Such a polarizing approach to knowledge types of knowledge, one explicit and abstract, is refl ected in the conceptualization of docu- and the other situated. For instance, Polanyiʼs ments and information systems. Documents (1983) distinction between "tacit" and "ex- are often depicted as containers for abstract, plicit" knowing is often used to characterize formal, homogeneous knowledge that can two types of knowledge or justify related di- be easily transported across settings. In turn, chotomies, such as "local" versus "universal", these containers are not capable of capturing "know-how" versus "know-that", "formal" and disseminating local, messy, heterogeneous, versus "situated", "canonical" versus "non- and concrete knowledge. Taking a step back, canonical" (Orlikowski, 2002: 253). Each of one could argue that this framework addresses these conceptual pairs draws on different lit- the question raised above, whether people can eratures and stresses unique theoretical points. share situated knowledge beyond the context However, if we glance over these individual in which it is embedded. And, the answer is variations we fi nd an overarching dichotomy no. People share abstract codifi ed knowledge cutting across these conceptual pairs.
– not situated and contextually embedded One pole treats knowledge as abstract rep- resentations, a perspective that has informed In other words, documents and the know- studies of managerial cognition (Walsh, 1995; ledge represented in them are pictured as Walsh & Ungson, 1991). In the medical fi eld hovering above the realm of the empirical and this would be the abstracted, explicitly rep- contextual. Two opposing discourses about the resented and codifi ed knowledge taught in organizational role of documents and informa-medical schools. The other pole approaches tion systems easily follow (Berg, 1997a). On 40878_outlines 2003 nr2 45 3/31/04, 14:50:43 Carsten S. Østerlund • Documenting Practices
one hand, we fi nd the position with the power utilized in our unfolding communication, co- of information systems and formal tools resid- ordination, and knowledge exchanges.
ing within their ability to capture and detach The following section introduces Hanksʼ knowledge from its context without losing its analytical approach to communicative prac- essence. The document provides a mode of tices or what, in the medical context, you could transporting abstract knowledge across set- consider documenting practices. This will set tings. An opposing discourse argues that for- the stage for our return to Marc and Elisabethʼs mal and abstract knowledge captured in docu- case, allow us to analyze their specifi c docu- ments represents an impoverished version of menting practices and help us understand why the richness of the empirical world and situated they deem it necessary to maintain separate knowledge. Abstract models cannot but delete on-line note systems.
the details of the heterogeneous work that they represent. This creates infl exible systems that will inevitably result in improper functioning Genres and the indexical
when the information system is implemented centering of documenting
(ibid.: 405). The fi rst could represent the dream
of the universal patient-centered record; the practices
second would fi nd support among many health-
In linguistics we fi nd a dichotomy comparable care providers who distrust the viability and to the distinction between abstract and formal timely implementation of large-scale medical knowledge versus the local and situated know- ledge divide found in organization and infor- These positions seem too entrenched; the fun- mation system studies. One body of linguistic dations too essentialist. Moreover, they do not theories focuses on the patterned, abstractable, help us explain Marc and Elisabethʼs case. These universal, repeatable, and arbitrary aspects of two doctors clearly share practices and work language and communication. From such a contexts, why donʼt they also share information formal perspective, medical communication system? The question becomes, what roles do the genres consist of regular groupings of thematic, HOSO and Senior Note systems play in their daily stylistic, and compositional elements (Hanks, work and knowledge sharing practices? 2000). Generic types of medical documents In this paper I attempt to articulate an ap- are defi ned by differences in features or confi g- proach to information technology in organiza- urations, no matter the social values associated tions that addresses these empirical questions with them in a given context or the historical by overcoming the overarching dichotomy conditions under which they come to exist.
between the abstract and situated. I will do so A family of approaches promotes the in- by approaching medical documents as com- verse thesis – that our communication is vari- municative genres. Following the lead from the able, locally adapted, saturated by context, linguistic anthropologist William Hanks (1990, and constantly adjusting to the world beyond 1996, 2000), I adopt a view of communication its limits (Hanks, 1996). Here, medical genres that ties it to practice. Hanksʼ framework al- can be defi ned as the historically specifi c con- lows us to stay clear of the abstract-transfer- ventions that doctors and nurses apply when able versus situated/context-bound dichotomy composing documents and audiences receive by studying how knowledge is carried, not by them. From this perspective, genres consist of our cognitive processes, but in the way we use orienting frameworks, interpretive procedures language in practice. Documents are no longer and sets of expectations that are not part of mere vessels for abstract knowledge but tools the formal structure (Hanks, 2000), hence the 40878_outlines 2003 nr2 46 3/31/04, 14:50:44 Outlines • No. 2 • 2003
ways in which doctors relate to and use med ical ation of her utterance because it connects the language defi ne a genre. This approach has a semantic code with the concrete circumstances long history in the social sciences where the of its use. The doctor would have been left interaction among language, culture and indi- rather perplexed had he received the answer vidual lives is placed at the center of analysis. "down there" from a disembodied voice over It fi ts with Wittgensteinʼs later writings and the emergency roomʼs intercom.
phenomenologists such as Merleau-Ponty for The notion of "indexical centering" plays whom actions in the world were formative of a key role in Hanksʼ framework. The concept and not dependent upon the formal structures allows us to describe how people routinely summarized as grammar. make references to places, objects and times But, how do we move beyond this di- that defi ne the relations among the interacting chotomy? Hanks offers one attempt to move parties. One could argue that the nurse de- beyond the dichotomy between purely formal fi nes the context for her communication with and socially situated approaches to commu- the doctor through the indexical centering of nication and genre analysis by incorporating her utterance. In this way, the nurse simul- formal features of language, while still locating taneously makes reference to and articulates them in relation to everyday and historically with the context in which she performs her specifi c practices. He does so by shifting our focus away from the content of our commu- The nurse, however, is not limited to mak- nication as the thematized object. Instead, he ing references to and articulating with her approaches communicative content as mere re- present context; she could also do this across sources through which other parts of the world multiple contexts or places. Imagine that the are brought into focus by calling attention to a nurse knows that this newly minted physician set of linguistic terms known as "indexicals". started working in the emergency room only In language, such signs encompass demonstra- yesterday and wants to help the physician un- tives, pronouns, and other deictics1 or "shifters" derstand the organization of the emergency that relate utterances to their speakers, address- room. She may say: "We keep the orthopedic ees, actual referents, place and time of occur- patients down at the end of the hallway by rence (Hanks, 1996). For instance, a doctor in the elevator. That makes it easy to get them the emergency room asks a nurse at the nursing up to the radiology department." In this way station where he can fi nd Mr. Jones. The nurse the nurse centers her communication on the responds: "Down there." The nurseʼs utterance relation between the emergency room and the "down there" indexes her current location in radiology department upstairs.
the nursing station as a ground or center from In a similar fashion people can build into which she makes reference to the patient laying their indexical centering references to not only on a gurney down the hallway. This "indexi- other places but also other times or relations cal centering" embedded in the nurseʼs answer across situations. This point becomes par- is a primary part of the physicianʼs interpret- ticularly important when we introduce docu-ments as expressive mediums, part of the form through which practices are realized and com-munication accomplished. Written communi- 1 Deictics are words showing or pointing out directly the cation builds around indexical elements to the one referred to and distinguishing it from others of the same degree as face-to-face communication. same class. For instance, the demonstrative pronouns People may use a document to index their com- this, that, and those have a deictic function (Encyclo-pedia Britannica Online, 2001).
munication within one very limited context. 40878_outlines 2003 nr2 47 3/31/04, 14:50:46 Carsten S. Østerlund • Documenting Practices
Likewise, they may use a document to build of mutual perceptibility or prior knowledge. an indexical fi eld that points to relations across The interacting parties may have face-to-face multiple situations, times, and places.
interactions with one another or their relation- In Hanksʼ framework, knowledge ex- ship may be defi ned by great distance. They changes are no longer either situated and may share a common knowledge and full set context bound or abstract and transportable. of referents based on prior experience together People situate their communication in an or they may never have met. All those factors, extremely narrow context by constricting according to Hanks (1996), affect the use of the temporal and spatial range of their in- deictics and the indexical centering of particu- dexical fi eld, or they can situate it in relation lar communicative practices.
to times and places far beyond the reach of Second, the relationship between the inter- face-to-face communication. This makes acting parties and the object of referent, wheth-Hanksʼ notion of "indexical centering" a er a patient, an object, a place, or a temporal promising candidate for overcoming the di- rhythm, can vary greatly. The relationship to chotomy between the abstract transportable the referent may be characterized by a com- knowledge versus situated and context bound mon knowledge or a more or less asymmetric knowledge. Furthermore, Hanksʼ framework access. Both parties may interact with the ref- becomes the key to a deeper understanding erent, e.g. a patient, on a daily basis, or one of medical documents and the role they play doctor could be reporting on his or her relation in the communication, collaboration, and co- to the patient to another physician who has no ordination among doctors and nurses. The prior knowledge of that patient. These aspects structure of indexical referential terms em- of the situation help defi ne the indexical center- bedded in different medical document genres ing of particular communicative genres and the can serve as a window into how doctors and structure of individual deictics and the way nurses position their communication and they map the interactive space.
knowledge exchanges in the complex health- To compare and contrast the HOSO and care fi eld involving countless participants, Senior Notes along these two main dimensions places and temporal rhythms.
of the indexical centering of communicative genres, I look for differences and common-alities in the text-to-context relations across Methodology and fi eld site
these two genres. More specifi cally, I focus on In this article, I attempt to analyze the indexical the references to author, addressees, and other centering of two medical genres, the internsʼ participants; references to places, place-names, HOSO and the senior residentsʼ Senior Note. locative descriptions, dates, signatures, spatial The analysis falls along two main dimensions and temporal deictics; and other spatial and in the indexical centering of deictic references: temporal markers. To protect the privacy of the relationship between the interacting parties both healthcare providers and patients I have on the one hand and the relation between the changed all names, dates, institutional identi- interacting parties and the object of reference fi ers (e.g., record numbers, phone numbers, on the other hand (Hanks, 1996: 182).
department names, and institutional names), First, the degree of access between the and sometimes the gender of my informants. interacting parties plays an important role The examples of records included in Figure defi ning the indexical centering of particular 2 and 3 below are excerpts from fi eld notes documenting practices and the text-to-context that did not contain any patient, clinician, or relations. Peopleʼs access can vary in degrees institutional identifi ers. Those identifi ers were 40878_outlines 2003 nr2 48 3/31/04, 14:50:47 Outlines • No. 2 • 2003
never copied from the originals in the process record systems, and whiteboards. In this work of the fi eldwork.
I focus on two record entries in an attempt I draw my empirical case from a 15- to illustrate the analytical power of a specifi c month, multi-sited ethnographic study in type of linguistic analysis.
several pediatric healthcare settings, fol- Finally, a note on terminology. I prefer to lowing patients from primary care clinics use the term "documenting practices" in place to emergency rooms and in-patient units in of Hanksʼ "communicative practices" (Hanks, a US metropolitan area. In this larger study I 1996). Hanks builds his conceptual framework focused on the collaboration among doctors, on detailed ethnographic studies of face-to- nurses, and clerical workers, specifi cally the face communication in Maya on the Yucatan practices that go into documenting patientsʼ peninsular of Mexico or historical analysis of care (Østerlund, 2002). The doctors and nurses colonial texts from Yucatan. Thus, he does were the actors of that study. They cared for not study the role of documents as an integra- patients that moved through the locales they tive part of peoples evolving communicative practices. By using the term "documenting The present paper can be distinguished practices" I hope to highlight the central role from the larger study in at least three ways. documents play in the structuring of everyday First, where the larger study positions itself work practices and knowledge sharing in or- in a broader debate on the social and organ- ganization. In short, my unit of analysis is the izational implications of medical information documenting practices of doctors and specifi c- systems (see (Berg et al, 2003) the present ally the practices that go into documenting pa-paper takes a far more narrow approach. Here, tientsʼ care.
I hope to highlight the potential of linguistic The argument is structured as follows: analysis for sociotechnical studies of medical Before we turn to the two dimensions of in- documents. Specifi cally, I want to draw at- dexical centering outlined above I will briefl y tention to Hanksʼ approach to language as a look at the more formal genre features that go communicative practice. Analyzing language across these two documents. In other words, as practice allows us to tie language use to we will start out with a more "content-based" broader social practices and how document analysis focusing on formal features character-use allows people to deal with the distributed izing these two texts and medical documents nature of their daily lives and work practices. in the US in general. This is fi rst followed by Secondly, the broader study focuses on the a discussion of the relationship between the documenting practices of nurses, physicians, interacting parties, and secondly an analysis and clerical workers. To look across occupa- of their relationship to the referent, that is, tional groups and involve both patientsʼ and the patient.
cliniciansʼ perspectives are important if we want to understand the implications of medi- Content-based Analysis:
cal information systems. I do not attempt to address these broader issues in this paper but simply focus on a narrow slice of two physi- Elisabethʼs senior notes (Figure 2) and Marcʼs ciansʼ documenting practices. Third, I fi nd HOSO (Figure 3) both adhere to the same gen- it important to take an inclusive perspective eral genre format: the subjective data, objective on medical information systems and include data, assessment, and plan (SOAP). Figure 1 all records in my analysis, whether made on summarizes the issues subsumed by this acro- various note cards, preprinted forms, on-line nym. Nurses and doctors engage this narra - 40878_outlines 2003 nr2 49 3/31/04, 14:50:49 Carsten S. Østerlund • Documenting Practices
Figure 1 – SOAP: Subjective Objective pict clinical work as a type of experimental or Assessment and Plan "scientifi c" activity. Weed explicitly labeled the distinct steps in the clinical process (i.e. SOAP) as elements of the scientifi c method. Identifying InformationChief Complaint (CC) The hope was to lay open medical practice History of Present Illness (HPI) to scientifi c analysis in a new and thorough Past Medical History (PMH) way. The individual steps of the experiment, Medication and allergies the defi nition of the starting point, the plan- Family History (FH) ning of the intervention, and the observation of Social History + habits (SH) the outcome should be discerned and judged. Through the problem-oriented record, the doc- tor "is able to organize the problems of each Review of Systems (ROS) (including an or- patient in a way that enables him to deal with dered list of every relevant organ, noting the them systematically" (Berg, 1997b: 23; Weed, present or absent symptoms referable to that 1968). For a thorough discussion of Weedʼs writings and their attempts to standardize Physical Exam (PE) medical work see Berg (1997b) and Timmer- mans & Berg (2003).
The patient histories found in Elisabethʼs Senior Notes follow the SOAP format nearly Assessment
to the letter. The header and the fi rst paragraph Diagnosis or differential (list of possible diag- of the two histories included in Figure 2 sum- marize Dylan Jones and Anna Hagueʼs "sub-jective data". These include their name, record number, an acronym, ASSN, which means that Treatment regiment or other action taken by their case is assigned to an attending physician in the hospital and not their own primary care tive structure when presenting individual and doctor; this is followed by, admission date, the patient histories both verbally and in writing. name of the intern in charge of their case, and Many medical schools and teaching hospitals the patientʼs age, and chief complaints. Chief strongly promote this organizing structure for complaints can be symptoms or diagnosis or history giving, including Kiltham Hospital. a mix of the two. We learn that both patients, Marc and Elisabeth readily recite the SOAP only a few weeks old, suffer from viral bron- elements if asked.
chiolitis. In addition Dylan Jones has a newly The SOAP builds on a widespread genre diagnosed heart defect (i.e. ASD), possible gas- for medical histories in the US. Structured teroesophageal refl ux (GERD), and failure to formats for history records can be found as thrive (FTT). The latter is a catchall diagnosis early as the nineteenth century (Epstein, 1995). for children who do not follow normal growth The present system began to be established in patterns. The fi rst paragraph summarizes in a the early nineteenth century and became codi- telegraphic style "history of present illness", fi ed in the last decade of the century. In the "past medical history", "medication and aller- nineteen sixties the American physician Law- gies", "family history", and "social history". rence Weed introduced the SOAP format as Dylan presented in the Emergency Room (ER) the guiding structure for his "problem-oriented after three days of coughing, vomiting, and de- patient record" in an attempt to design and de- creased eating. The ER doctors admitted him to 40878_outlines 2003 nr2 50 3/31/04, 14:50:51 Outlines • No. 2 • 2003
Figure 2 – Excerpt from Senior Notes Showing First Page and Two EntriesNotice: This fi gure contains no real patient, clinician, or institutional identifi ers. Wednesday, February 23, 2002
Elisabeth Lave #124 Marc Bergger #343 Heinrich Schreiber #89 Patrick Dreier, M.D. (ASSN) #482 Oscar Hanks #1193 John Van Fennen #87 Tina Law, M.D. (Teaching) #104 Gabriel Callon #432 Roger Moore #1596 Jennifer Latour #987 10E Conference Room PTB Senior Call Room 1 mo RSV bronchiolitis, ASD, PPS 12 do UTI, persistent fever, leukocytosis 3 yo cervical adenitis 11 month fever, tachypnea,? acidosis 5 wo RSV+ bronchiolitis, ICU transfer 5 mo RSV+ bronchiolitis, ICU transfer 2 month old vomiting/cough, hx of FTT 5 wo RSV + bronchiolitis, ICU transfer.
4 wk mild bronchiolitis, murmur, social 10 W Willey, Vienna 8 yo ataxia telangletasia, pulmonary AVM 9 do conjunctivitis, r/o sepsis 6 mo bronchiolitis 3 yo RML pneumonia, fi rst RADexacerbation 9 y/o HSV vaginitis McDonald, Mike 764 15 yo SLE, worsening BUN, left foot pain 10 yo viral meningitis 11 wk old with Salmonella bacteremia 40878_outlines 2003 nr2 51 3/31/04, 14:50:52 Carsten S. Østerlund • Documenting Practices
15 yo MCTD, LLL pneumonia 14 yo Hgb SS, VOC (necklabd pain) 7 yo Hgb SS, abdominal VOC, s/p ICU 9 mo Trauma X, shaken-baby syndrome 15 yo Hgb SS, abdominal VOC, NO study Jones, Dylan
1 mo RSV bronchiolitis, ASD, PPS
1 mos old presented with cough x3 days, question of decreased PO and vomiting. Got r/osepsis for fever in ER. Recently admitted 2/7 for rule-out sepsis. In ER, taking pedialyte PO, 37.6, 172, 48-88, 100%. Not wheezing, no G/F/R. CXR with RML atelectasis. WBC=11.4 (28P,55L,4Bd), Hct=31.5, Plt=455. Bicarb 18. UA neg. Lytes wnl. Urine and blood cultures pending. Mom and child live in a shelter. PMH Born FT 7lbs 5 oz. On 01-15, reportedly 8 lbs 12 oz. On admission 7 lb 14 oz.?FTT RESP: increased interstitial markings prob due to pulm edema, now resolved;?patch infi ltrates c/w Chlamydia; vapo nebs prn. Initially thought the tachypnea was due to CHF. Gave Lasix. On 2/18, had RR to 110. Gave Alb and Vaponebs with out improvement. ABG showed 7.45/24.9/127/17. CXR showed hyperinf SSA. Transferred to ICU. Tachypnea improved. Respond to Vaponebs but not albuterol. On RA with good sats. RSV came back Positive! CV: CXR with heart size upper limits nl, 4Ext BPs nl, R sided axis on EKG. Liver edge down, ECHO with large ASD, and left PPS and RV hypertension. On fl oor, tried to diurese with lasix. Now stop-ped. Cardio following – now things resp issues not cardiac. F/u in clinic for ASD.
FEN: newborn screen wnl; came in only 3.6 kg. Lost 0.8 kg after diuresis. Looks cachetic with decreased muscle bulk.?poor nutrition,. W/U for FTT. They placed an NJ tube in ICU due to resp distress and FTT issues. Started Prosobee at 5 cc/hr/ (hx of rash with Enfamil). Nutrition consult. Also? GERD due to hx of back arching – started Zantac. Increased to full feeds on fl oor. NJT pulled and now po feeding, gaining weight.
ID: cultures pending; started on erm for?atypical – changed to Azithro in ICU x 5 days (ends 2/24); rsv positive.
SOCIAL: 443 8700 x987 Peter NP. Mother lives in a shelter. 2 step-children SW involved.
Hague, Anna
ASSN 2/15
5 wo RSV + bronchiolitis, ICU transfer.
5 week old FT/LGA previously healthy with RSV + bronchiolitis transported from Common Hospital 1/29, in ICU intubated 1/29 to 2/12 (on Hifi for portion), transferred to fl oor 2/15.
Pulm: Wean O2 prn. Pulm consulted regarding weaning of diuretics. Attempted to d/c but developed fl uid overload requiring Lasix 1 mg/kg so restarted. Now on room air.
CV: H/o murmur. Echo showed PPS. Currently stable.
ID: RSV+. Trach cultures grew S. aureus (sensitive to oxac & clinda), S pneumoniae, and Morazella. On Zosyn and Vanco in ICU initially, changed to Unasyn and Ampicllin, d/c 2/11. Now afebrile off antibiotics, Eye d.c PSA and serratia. Gentamicin & Ilotycin eye ointment.
GI: On NJ continuous feeds when transferred from ICU. Now on po feeds.
FEN: In ICU, high HC03 (40ʼs) due to lasix. Chlorothiazide & spironolactone PNJT q 12 hrs,follow lytes qD. Bicarbs down to 30s. May need to go up on diuretics b/c UOP not great.Heme: Hct 29.
Neuro: On methadone and ativan taper. Low NAS scores so d/cʼd 2/17. Increased sweaty and irritable on 2/19, NAS score 11 – given small dose of Ativan.
Dispo: Discharge pending when off 02, full feeds, and sedatives weaned.
40878_outlines 2003 nr2 52 3/31/04, 14:50:54 Outlines • No. 2 • 2003
Figure 3 – Excerpt from HOSO Showing Two EntriesNotice: This fi gure contains no real patient, clinician, or institutional identifi ers. HOUSE OFFICER SIGNOUT
Wednesday, February 23, 2002 06:56:12
RSV BRONCHIOLITIS ECHOCARDIOGRAPHY RACEMIC EPINEPHRINE 0.25CC NEBS PRN AZIHIROMYCIN ENFAMIL ALLERGIES: NKDAPLAN/ON CALL SCUT: 6 wk old boy s/p ICU for RSV bronchiolitis, now w/ remaining FTT, ASD and GERD symptoms Resp: On RA. On azithromycin for 5d course for Chlamydial pneumonia CVR: ASD stable, felt to be playing role in FTT picture GI: On Zantac, ad lib po feeds. Nutrition consult. Follow for sx refl ux Cards: ASD stable, cards following.
Soc: SW consult. Parents in shelter, in need of support. Appropriately concerned.
rule-out infection as the underlying course of long-term cardiovascular care to the outpa- his symptoms. The next few lines summarize tient clinic.
his vital signs taken in the ER and the proce- In Annaʼs case, we learn under the pul- dures he went through. Finally, we learn that monary subheading, for instance, how she re- he lives with his mother in a shelter and that ceived concentrated oxygen through a mask. he gained weight in the fi rst weeks after birth, This was later discontinued and she is currently which he subsequently lost again. In Annaʼs breathing room air. An oxygen mask may still history we learn that she was born large and be used if found necessary. After an attempt to healthy at full term. Soon after, she got viral wean her of diuretics failed, Anna developed bronchiolitis leading to her fi rst admission at a fl uid overload – leading to the involvement of small suburban hospital (Common Hospital). the pulmonary team as consultants. Annaʼs his- They transferred her to the ICU at Kiltham hos- tory concludes with a disposition/plan: she will pital where she was intubated for two weeks be discharged as soon as she does not require before getting transferred to one of the hospi- an oxygen mask, eats normally, and has been talʼs pediatric medical units, 10 East.
weaned off the sedatives originally started in The rest of Dylanʼs and Annaʼs histories the ICU as part of an aggressive treatment review what is considered relevant organ regiment. Dylanʼs history does not contain groups for their cases, or rather relevant a separate section on his disposition, which sub-specialties in the hospital. In Dylanʼs could mean that the physicians have not yet case this includes respiratory (RESP), car- made a discharge plan for him, as too many diovascular (CV), fl uid electrolyte nutrition questions remain unanswered.
(FEN), infectious Disease (ID), and social Marcʼs HOSO (Figure 3) stands out as a services. In Annaʼs case the note calls at- signifi cantly more schematic and truncated tention to pulmon ary (Pulm) cardiovascular, summary of Dylan and Annaʼs cases compared infectious diseases (ID), gastrointestinal (GI), to Elisabethʼs Senior Note. For instance, the fl uid electrolyte nutrition, and neurology. HOSO reduces Annaʼs case to a few lines. We Each of these subsections reviews Dylanʼs learn that the physicians consider her respira- and Annaʼs "objective data", "assessment", tory distress and viral bronchiolitis as treated by todayʼs date. In addition they can give her In addition, the authors elaborate "history the medications Albuterol and Tylenol if need- of present illness" as they sum up test results ed. Nevertheless, the HOSO contains most of and give their assessment and plan. In other the SOAP genre elements – though, presented words, the review of each organ group con- out of order. The HOSO sums up Dylan and tains a small narrative that justifi es the actions, Annaʼs "subjective data" in the header, and assessment and plans taken. For instance, in under the sections on problems, procedures, regard to Dylanʼs cardiovascular system (CV) medications, allergies, and the fi rst line of the we learn that an X-ray showed an enlarged section "plan/on call scut". The term "on call heart and an echogram later unveiled a heart scut" refers to the work pending for the intern defect. Treatment with lasix was tried but later in charge. In Dylanʼs case we learn that his abandoned. The cardiovascular team now fol- bronchiolitis and heart problems were diag- lows Dylanʼs case, and they do not perceive nosed on October 6th and 7th. On the same day his heart problems as directly related to the the echocardiography was conducted. Equally respiratory problems triggering his hospital important to the interns responsible for the pa-admission. Based on these analyses the plan tientsʼ medication, the HOSO contains a list is to pass over the responsibility of Dylanʼs of the medications currently given to Dylan. 40878_outlines 2003 nr2 54 3/31/04, 14:50:57 Outlines • No. 2 • 2003
One sentence captures the history of his current if he could just read the senior residentʼs more illness; originally he was admitted to the ICU complete account of his patientsʼ histories? for bronchiolitis. Since then three other issues Or, the senior resident could have the interns have emerged including failure to thrive, heart write a more detailed note freeing up time for problems and refl ux.
the senior resident to engage in research or Comparable to the Senior Notes the HOSO other high prestige activities? In an attempt envelops the "objective data", "assessment", to address these questions we will now turn and "plan" into a review of systems compiled to an analysis of the indexical centering of the in the section, plan/on call scut. The HOSO HOSO and Senior Notes respectively.
does not review test results but simply high-lights important issues and points to the sub-specialties involved. In Dylanʼs case we learn, fi rst, that he is on room air and on a fi ve-day A key element in our practice-based analy- course of medication for pneumonia. Second, sis of medical records is the grounding of the cardiac consulting team follows Dylanʼs the more generic genre elements in their in- heart problems, which they believe may be the dexical context. We recall that indexicality underlying cause to his failure to thrive. Third, is a semiotic mode in which signs stand for the nutrition consult team follows Dylanʼs re- objects through a relation of actual contigu- fl ux symptoms and has put him on a special ity with them (Hanks, 2000: 151). Pronouns, baby formula diet (i.e., Zantac). Finally, the demonstratives, and other "shifters" relate ut- HOSO highlights Dylan and his familyʼs liv- terances to their speakers, addressees, actual ing situation and that a social worker team referents, places and times of occurrence. follows his case.
Indexical centering plays a principal role In short, the Senior Notes and the HOSO in the interpretations of medical documents include the same formal genre elements. With as it connects the evaluative and semantic small variations the two records follow the code with the concrete circumstances of its SOAP format. What stands out, are the sig- use. The Senior Notes and HOSO genres nifi cant differences in length and detail across embody specifi c kinds of public address by the two record types. The senior note provides a collective of speakers, before a collective a comprehensive account of Dylan and An- of addressees and about a group of patients naʼs care. The HOSO is conspicuously brief in and colleagues, all located in a carefully con- comparison; Annaʼs case seems astonishingly structed "here" and "now". First, I analyze abbreviated. The HOSO leaves us no sense the indexical centering of the relationship be-of her treacherous tour through the healthcare tween the interacting parties. Second, I turn system starting at one hospital, transferred to to the deictic system defi ning the indexical Kilthamʼs ICU and later moved to an inpatient ground of the relationship between the inter- unit, 10 East, where she has been treated with acting parties and their object of reference, methadone for withdrawal symptoms caused the patient.
by the intensive medication she received in the
ICU. These signifi cant differences in length Interacting parties: Addressivity, spatial
and comprehensiveness across the two records
fi eld, and temporal fi eld
raise the questions: why these differences? The indexical centering of the relation be-More specifi cally, why do busy interns like tween the interacting parties can be broken Marc spending more than 90 hours a week in down to the deictic references to participants, the hospital take the time to write the HOSO or "addressivity," and the spatial and temporal 40878_outlines 2003 nr2 55 3/31/04, 14:50:59 Carsten S. Østerlund • Documenting Practices
fi elds for interaction. Let us start out looking add the event to the HOSO. Elisabeth shares at what Bakhtin calls a genreʼs "addressivity" her notes in the Senior Notes on-line system (Bakhtin, 1986). Different genres correspond with other seniors only.
to distinct conceptions of the addressers and On her on-call nights Elisabeth covers for addressees. The addresser or addressee may not only patients at Pediatric Team B but also be an individual, a social group, contempor- two other departments. When the senior resi- aries, successors, an unconcretized Other, or dents in those other units sign-out, Elisabeth a combination (Hanks, 2000: 151).
prints out a new version of the Senior Note containing all patients currently in all these Addressivity and participants three units. The Senior Note printout can eas- In the Senior Notes and HOSO we do not fi nd ily contain 30-40 patients. In other words, any explicit address apart from the name of Elisabeth builds on other senior residentsʼ each document genre. Senior Notes address entries rather than writing Dylan and Annaʼs senior residents and House Offi cer Sign Outs histories anew. Senior residents in the ICU (HOSO) address house offi cers, the latter being most likely wrote parts of these two histories; physicians in Kilthamʼs residence programs, Elisabeth and other senior residents later edit including interns (fi rst year residence), second those earlier entries to make them refl ect the and third year residence. In Kiltham interns current status of a patient. When I fi rst started predominantly use the HOSO. Equally import- my fi eld research, these practices puzzled me a ant and in contrast to the majority of medical great deal. One late afternoon I asked a senior documents, neither the Senior Notes nor the resident why he just spent 45 minutes editing HOSO identify the speaker. We fi nd no sig- entries originally initiated by other senior resi- natures or specifi cation of who tailored these dents. He responded: documents. In the HOSO we do fi nd Marcʼs name in the header to Dylan and Annaʼs entries "Iʼm anal. I want the notes to follow a specifi c as the "Intern". This does not mean that Marc setup. No empty spaces. Look at this one [point-ing to a particular voluminous patient entry on is the sole author of the record; simply that he the screen]. Itʼs so long that you think that itʼs a is in charge of these two patients during his complicated case, but itʼs just a 4 month old with rotation in the Pediatric Team B.
Senior Notes and the HOSO are commu- nal documents where a distinct social group In short, Senior Notes and the HOSO stand constitutes each genreʼs collective addresser out as communal documents where authors and addressee. Most likely three or four sen- and addressees overlap and individual con- ior residents have been involved in the writ- tributors take on the role of contemporaries ing of Dylan and Annaʼs histories. Likewise, and successors interchangeably. People spend Marc did not write all parts of the HOSO. For hours making factual changes but also minute instance, if we return to the day where Marc modifi cations to the recordsʼ lengths and style and Elisabeth examine Dylan and Anna, we – thereby adhering to communal genre require- fi nd that in the late afternoon, just before going ments about how best to signal, for instance, home, Marc signs-out his patients to one of the potential workload involved in each case.
his fellow interns, Donna, who is staying in Where the HOSO and Senior Notes contain the hospital overnight. They use the HOSO to no explicit speaker and address, they do con- structure their conversation. Overnight, Donna tain references to the current community of par- uses the HOSO to structure her activities. And ticipants or contemporaries. At the beginning if anything happens to Dylan or Anna, she will of the Senior Note we fi nd a table listing the 40878_outlines 2003 nr2 56 3/31/04, 14:51:01 Outlines • No. 2 • 2003
names of senior residents, interns, medic al stu- vate physician or other sub-specialties, in this dents, and attendings. The four senior residents case Patrick; the other, Law, supervised the named on the left hand side are all contempo- teaching of the medical students. Given that raries to the current record and this group of pa- the attending physicians hold the ultimate re- tients. Elisabethʼs name goes fi rst signaling that sponsibility for patient care, one may expect she is currently in charge of the patients admit- to fi nd them in the fi rst column. However, the ted to Pediatric Team B. The other three senior senior residentsʼ "ownership" of the record residents all cover for her on different nights of most likely explains this inconsistency in the the week. In the HOSO we would get a com- sequencing. In short, the table recaps the in- parable sense of the author/addressee contem- teracting parties. It goes beyond the relations poraries if we printed out the entire HOSO for among speakers and addressees by including Pediatric Team B. If we read the right hand side the interacting parties involved in the care for of the headers for each patient, we would fi nd a group of patients.
the names of the four interns on Marcʼs team. Each of them would be assigned as responsible Spatial fi eld for a portion of those patients.
Elisabethʼs Senior Notes contain an explicit Apart from the names of senior residents structure demarcating the spatial dimensions and interns involved in their respective com- for her collaboration with the other members of munal system of "addressivity", we fi nd a host Pediatric Team B. Following the table we fi nd of names referring to other participants. These on the right hand side a list of three important include names of medical students, attending places and their phone number: 1) Pediatric physicians, patients, acronyms for various Team B uses the 10 East Conference Room medical services (e.g. Cardiac, Heme, etc.) as their base for writing records, hanging out and other professional groups (e.g., social and working rounds. 2) The conference room is workers). In contrast to the implicit compo- located on the 10 East Ward next to the nursing sition of speakers and addressees among the station where all calls to the ward get directed. interns and senior residents, we fi nd an explicit 3) The PTB Senior Call Room is where senior structure referring to other collaborators, their residents hope to catch a few hours of sleep relationships and interdependencies.
when they are on-call at night.
Starting with the Senior Notes, the top of We also fi nd a number of less explicit the document includes a four column table spatial markers embedded in the fi rst section listing, not only the senior residents produc- of the Senior Note. First, notice the pager ing and using the senior notes, but also the numbers follow the physiciansʼ and medical interns, medical students and attending phy- studentsʼ names in the fi rst table. One can con- sicians with whom they currently collaborate sider these pager numbers a spatial reference on Pediatric Team B. The table demarcates a to mobile individuals or what Mizuko Ito calls group of contemporaries to the present docu- "networked localities" (Ito, 1999, 2001). Build- ment. The sequence of the four columns hints ing on the idea of networked locales one could at the power relations among the four groups. also read the patientsʼ record numbers in the The senior residents oversee the work of the third column as spatial references. Physicians interns, who manage and mentor the medi- often fi nd that a patientʼs record number is a cal students. The attending physicians watch more reliable locator than their name, the latter over the entire team by taking on a supervisory often being misspelled or the same name held role. One attending physician is responsible by several patients. Second, we fi nd a blurring for the patients not attended to by their pri- of the distinction between place and partici- 40878_outlines 2003 nr2 57 3/31/04, 14:51:02 Carsten S. Østerlund • Documenting Practices
pants in the fourth column in the senior noteʼs that may need attention during the night, dif- table of content. This column summarizes the fi cult orders and other tasks.
service in charge of each patient. PHA is the As in the case of the spatial references, hospitalʼs outpatient clinic and a physical place. the Senior Note starts out by demarcating an In contrast, IMMUNO stands for immunology. explicit temporal structure for their work in This sub-specialty does not have its own clinic Pediatric Team B. With a glance at the top of per se where patients go. The immunology the senior note we learn that the daily work for team moves from ward to ward to consult on the senior residents structure around working specifi c patients. Much like the pager numbers rounds at 7:30, radiology rounds at 9:20 and these names refer to specifi c social spaces and Senior rounds at 10:00. All the members of participants, which may and may not be asso- Pediatric Team B outlined in the table par- ciated with a physical place. Interns and senior ticipate in work rounds and radiology rounds. residents pay attention to those spatial signals During those rounds the team will go over each afforded by various technologies such as their patient case, typically initiated by the intern or pagers. Over lunch one day a group of interns a medical student, recounting the patientʼs his- discussed how best to discern the physical lo- tory and progress. Radiology rounds take place cation of a page based on the call back number in the radiology department where the team displaced. The team uniformly agreed that when will huddle around a radiologist who will go a page was coming from the hospitalʼs cafeteria, over the latest x-rays and scans. Afterwards the they expected it to be cardiac team member try- group splits up. The senior residents will go to ing to get in touch with them. The cardiac team their Senior Rounds while the rest of the team tended to gather and work in one corner of the starts working on individual patient cases. In cafeteria close to the library.
the late afternoon Elisabeth will sign-out to the senior resident staying over night. Marc will Temporal fi eld sign out to the intern staying in the hospital Temporally, interns and senior residents struc- over night. If they are on call themselves, the ture their HOSO and Senior Notes use around other senior residents or interns will sign out change of shift, rounds, and sign-out. The fi rst their cases to them.
thing an intern or senior resident does when These two communal document genres arriving at work, is to log-on to the HOSO or become an integrated part of the hospitalʼs Senior Notes respectively. In doing so they staggered structure of coverage where staff determine if their on-call colleagues added groups in sequential shifts will overlap with any signifi cant information over night. Dur- one another for several hours or just 15 min- ing the day, and in particular in the afternoon utes. The notes help smooth transitions by and late evenings, interns and senior residents providing incoming doctors with immediate update their communal note systems. In the sources of information and reference from afternoon there is a fl urry of activity in the 10 the moment the outgoing staff members leave East conference room when interns get ready the hospital. This explains why house-offi cers to sign-out their patients to the on-call person. make an extra effort to write particularly de- When two interns were asked what time of tailed notes in the HOSO and Senior Notes day they considered the most important, they on the last day of their rotation. Interns strive answered in unison: "Sign-out". Interns update to discharge all their patients but if that is not the HOSO, and during sign-out use it to struc- possible, they write to capture as much detail ture their report to the on-call colleagues. In as possible to make it easier for the next intern their conversation they focus on the patients to take over their patients.
40878_outlines 2003 nr2 58 3/31/04, 14:51:04 Outlines • No. 2 • 2003
In summary, interns and senior residents new and larger space of interaction. Marc and associate specifi c times of the day with their his fellow interns do not need to be reminded communal document genres. Each group of the spatial and temporal dimension of their carefully maintains the coordination among interaction fi eld every time they look at their its members in regard to these times and the HOSO. It is the same for several weeks and, in documenting practices involved. These two case they should forget, they do keep a log of communal document types tie closely to two it on a large whiteboard in the 10 East confer- patterns of temporal coordination described ence room where they typically type up their by Zerubavel in his study of hospital work, notes. Elisabeth does not share such a symmet- that is, temporal complementarity and stag- ric space with her fellow senior residents.
gered coverage (Zerubavel, 1979). The senior Senior residents happily spend their breaks note and HOSO allow the senior residents discussing the details and pitfalls of their rota-and interns to maintain temporal comple- tion cycle and how it cannot be compared to mentarity, permitting, for instance, Marc that of the interns. One evening in the house-to cover for Donna, his fellow intern, when offi cersʼ "dungeon", a group of three senior she goes home at night and vice versa. The residents and fi ve interns eat their cafeteria HOSO plays an important role in supporting dinners. On a large round table one fi nds staggered coverage. It is exactly in the over- remnants of other house-offi cersʼ meals taken laps between shifts that doctors (and nurses) earlier in the evening and scraps of paperwork discuss those communal documents.
left behind. Bags and other personal items lay At this point, one may ask why the HOSO, on available surfaces. An intern plucks ran- compared to the Senior Note, does not contain dom cords on a piano in the corner. Seated a comprehensive mapping of the participants, around the table, three senior residents discuss temporal and spatial structures making up its a particularly weak point in the way senior indexical fi eld. The key question here is the residents sign-out (take over from each other) degree to which interns have access to interns during the weekend. During the weekend the and senior residents have access to senior reduced number of senior residents do not have residents. We fi nd many graduations of mu- time to go to all the morning rounds, which tual access and the question becomes: to what means that no senior resident will see patients degree do the interns share mutual perceptibil- admitted overnight by the night-fl oat (a third ity and prior knowledge about their space of year resident on night duty). Sean, one of the interaction compared to the senior residents? seniors, states in a grave voice: "So, there may The answer is embedded in their spatial and be some patients who have been here for 24 temporal fi elds. For the fi ve weeks Marc and hours and nobody has seen them or knows his three other interns are on rotation in Pedi- what the issues are. Itʼs scary!" The intern atric Team B they share collaborators, spatial at the piano says in a small voice: "But the structure and temporal rhythm. Every morning interns have seen them and know." To which they listen as they each present old and new Sean promptly reply: "Oh yes, but we have patients. At night they cover for each other. In the code pagers (the pagers called if a patient contrast, Elisabeth works within the interac- goes into a coma or experiences a sudden and tion fi eld of Pediatric Team B during the day, serious deterioration of health). If you get a but at night she covers for other teams with code you would like to know who the patient different participants, spatial and temporal is and what the problem is." Another senior structures. When on-call at night, Elisabeth adds: "Yeah, you come up to the fl oor, who is prints out a fresh senior note demarcating her this? Is it asthma, strep…!? 40878_outlines 2003 nr2 59 3/31/04, 14:51:05 Carsten S. Østerlund • Documenting Practices
The Referent: Dylan and Annaʼs histories
admitted. We see that the team has eight pa- It is nearly impossible to talk about the relation- tients on 10 East, two patients on 10 West, fi ve ship between doctors without also specifying patients on 11East, and seven patients on 12 their relations to patients, as the past section South. In other words, the left hand column illustrates. Relations among the interacting par- serves as a fl exible map. The teamʼs patients ties constitute only one dimension of the HOSO are distributed all over the hospital and the con- and Senior Noteʼs indexical ground: the other fi guration of these locations changes through dimension is their relation to the referent, the the day as new patients get admitted and oth- patient.2 The HOSO and Senior Note operate ers discharged or transferred from the wards. with two levels of relations between the refer- A boy suffering from Sickle Cell disease is ent and the interacting parties. The two genres admitted to 12 South, as Elisabeth and Marc can be read as a compilation of individual pa- write their notes. When Anna gets discharged tient histories, each specifying the relationship in a few days the team may get another patient between caregivers and a patient. The HOSO on 11 West, and if Dylanʼs condition should and Senior Notes also present all patients as one deteriorate and require a transfer back to the object of referent, that is a compilation of all ICU, another patient may take his place on patients currently admitted to Pediatric Team 10 East. Elisabeth refers to her senior note B. This means that Marc and Elisabeth not only when determining where to go next or where read their notes when addressing individual pa- the nurse calling her about where a patient, tient issues; they use the records to give them an for example, Hugh Fisher, may be located. In overview of their current workload, i.e. all the addition, the table specifi es the distribution of patients admitted to the team. In other words, team members in relation to this larger body of the object of referent can be see as either an work. With a glance we can tell where Marcʼs individual patient or part of a cohort.
patients are admitted in comparison to Donnaʼs The bold section following the table and patients. We know how many patients Patrick timetable on the fi rst page of the Senior Note has been assigned and so forth.
illustrates this latter point. This section con- The interns use the HOSO in a similar stitutes a table of contents by compiling all fashion despite its lack of a summary table. the headings from each patient history in the Each new history starts with the patientʼs present version of the Senior Note. Each line location. A glance at the HOSO tells us that summarizes the department, patient, service Dylan and Anna both are admitted to 10 East. in charge, intern in charge, the patientʼs age, If more histories had been included in Figure and chief complaint or diagnosis. As an entity 3 one would see that they are sequenced the this table of content outlines a body of work same way as the Senior Note starting with the characterized by a particular confi guration of wards at the lowest fl oors and then moving up. participants and places. For instance, in the Marc and his fellow interns will fl ip through Senior Notesʼ table of content each line starts the HOSO when planning their day or where to with the name of the ward where a patient is call if he needs to know whether the patientʼs one primary care doctor is responsible for the care or an attending physician in the hospital is assigned to the case. In short, these two docu- 2 One could argue that patients and/or their relatives serve as not solely "referents" but also interact with the doc- ment genres serve as fl exible maps outlining tors. The patientʼs role in the healthcare encounter is the ever-changing relation between the phy- obviously central but for the purpose of this paper I will sicians on Pediatric Team B and all patients maintain my focus on the indexical structures within the two record systems. currently admitted to the service.
40878_outlines 2003 nr2 60 3/31/04, 14:51:07 Outlines • No. 2 • 2003
With this broader defi nition of the object of case: "1 mos old" (one month old). The rest reference in mind let us now turn to the indi- of the history mentions neither Dylanʼs name vidual patient histories and the indexical fi eld nor any pronouns referring to him. Each new those narratives outline in the interactions be- sentence seems to point back to Dylanʼs name tween physicians and patients. I start out with in the historyʼs header or the descriptive epithet the participants, followed by a discussion of opening the history. Only in the fourth line are the spatial and temporal fi elds.
the vocatives "mother and child" used in the sentence: "Mother and child live in a shelter." When it comes to healthcare providers we fi nd The HOSO and Senior Note outline another one pronoun referring to physicians in the en- level of participants in the body of Dylan and tire history: "They placed an NJ tube in ICU… Annaʼs histories. These participants do not " (line 14). In the rest of the text the vocatives have enduring relationships with the mem- "ICU" and ER seem to point to places and bers of Pediactic Team A. Their interactions not people. However, the boundary between are defi ned by the requirements of individual participants and place names blur. The nouns patientsʼ cases. For instance, Dylanʼs Senior "ICU, "fl oor," and "ER" refer to both phys- Note history mentions four groups follow- ical places, but also a collective of healthcare ing his case: "Cardio following", "Nutrition providers. In comparison, the "Pulm" (Pulmon- consult", "Peter NP", "SW involved" (i.e., ary team in Annaʼs history) signify a group social work). In contrast to the earlier section of healthcare providers not associated with a of the senior note, we fi nd no proper nouns physical place.
designating particular participants, with the In the HOSO we fi nd a comparable in- exception of Peter, a nurse practitioner in the dexical centering of the relation between shelter where Dylanʼs mother lives. The same participants and patients through the use of is the case in Annaʼs history. We learn that pronouns, epithets, and vocatives. Dylan is the pulmonary team has been consulted (i.e., referred to as a "6 wk old boy" at the outset "Pulm consulted"). The lack of proper names of the history (line 12) with no other direct referring to the physicians involved from the references in the rest of the text. As the senior different services may be explained partly by note, the HOSO points to the involvement of the loose relationship between the consulting "nutrition, card, and SW" (line 15-17). When services and the members of Pediatric Team B. the "anal" senior resident mentioned above Furthermore, the members of each subspecial- spends 45 minutes editing the Senior Notes ty rotate through their teams. The Pulmonary on-line, he, in fact, polices this particular team coming up to 10 East to check on Anna indexical system. Much of what he is edit- could easily be composed of different individu- ing down is previous senior residentʼs use of als from one day to the other. In contrast, the "too many" full sentences with pronouns and nurse practitioner, Peter has promised to fol- other direct references to participants. Like- low up on Dylanʼs case when he returns to the wise, medical students are known for writing shelter, an arrangement that has been set up by glaringly long histories. This is partly due to the nurses on Dylanʼs unit, 10 East.
their use of full sentences. Senior residents The histories stand out by their lack of pro- spend much energy and often abuse to teach nouns, and relatively few descriptive epithets interns and medical student how to cut their and vocatives referring to participants. A single histories down to the bare minimum. One in- descriptive epithet refers to Dylan and Anna in tern recalled over lunch his preceding surgi- the fi rst sentence of their histories, in Dylanʼs cal rotation where the senior resident insisted 40878_outlines 2003 nr2 61 3/31/04, 14:51:09 Carsten S. Østerlund • Documenting Practices
that the internsʼ Progress Notes should be no he lives with his mother. In the next section longer than seven lines long and that they (i.e., RESP.) we learn that he was transferred should leave space for his note at the bottom to the ICU. The CV section (cardiac vascular) of the Progress Note sheet. If not, he would mentions "the fl oor," Cardio, and F/u in Clinic tear up the document.
(follow-up in Clinic). "The fl oor" refers to his In summary, we recall that the Senior current admission to a general pediatric unit, Note provides a comprehensive mapping of 10 East. The FEN section refers to ICU, Nutri- current collaborators and their interdepend- tion, and the fl oor. The ID section mentions the encies. Interns do not use the HOSO to out- ICU, and the fi nal section refers to the social line the medical students, senior residents, worker team and the Shelter. We can depict and the teaching attending physician with this general trajectory as follows: Shelter => whom they are currently working on Pediat- ER => ICU => Floor, Cardiac => Clinic; ICU, ric Team B. Yet, when it comes to Dylan and Nutrition => Floor; ICU => Social, Shelter. In Annaʼs actual patient history we fi nd little short, these place names give us a general sense variation in the specifi cation of participants of Dylanʼs trajectory through the healthcare and their relation to the patient – despite the system from shelter to ER to ICU to fl oor to vast difference in length and detail between follow up care in the clinic and back to the the senior note and HOSO. For instance, we shelter again. Annaʼs history offers a compar- notice that regardless of the glaring lack of able sequencing of place-names: Common detail in Annaʼs HOSO history all it misses Hospital => ICU => Floor; Pulmonary con- is a reference to the pulmonary consult in- sult; ICU; ICU; ICU => Discharge pending. volved when she was weaned off diuretics. We notice that this by no means provides an The senior note does not mention any other accurate depiction of her care trajectory; yet, it participants in the body of the history. Interns offers a general sense of her move from Com- would most likely not regard this as an over- mon Hospital transferred to Kilthamʼs ICU, sight but simply as a fact that is no longer rel- transferred to the fl oor and now pending her evant to Annaʼs current care. In other words, discharge from the hospital.
it seems equally important to senior residents The repetition of ICU highlights that most and interns alike to index the relationship be- of the signifi cant event took place here. Simi- tween caregivers, including themselves, and larly, the header explicitly states that she is the individual patients.
an ICU transfer. To the senior residents this is important information that will prompt their Spatial references in the patient history attention. Otherwise, infants with bronchiolitis In Dylan and Annaʼs individual histories we do not receive much attention during the winter fi nd a number of place names – many of which months. The number of admissions with this are repeated several times. In the Senior Notes diagnosis is so high that their care is regarded Dylanʼs history, for instance, mentions the ICU as routine and something worth little consid- three times, and the fl oor and shelter two times. eration from the senior residents.
Reading those place names within their indi- The HOSO presents noticeably few place- vidual sections we fi nd that they are organ- names compared to the senior note. Annaʼs ized to connote Dylanʼs trajectory through a case stands out by containing no place names number of locales but seen through the lenses apart from the reference to 10 East in the of relevant organ systems. The fi rst section header. Dylanʼs history does reference his summarizing his past and present medical stay in the ICU and the current involvement history refers to the ER and the shelter where of nutrition, cardiac team, social workers, and 40878_outlines 2003 nr2 62 3/31/04, 14:51:10 Outlines • No. 2 • 2003
the shelter where his mother lives. However, before their chief complaint (e.g. their diag- we do not get a sense of the trajectory spelled nosis). The location is not random. Physi- out in the senior notes from ER over ICU to cians regard a four-week-old baby with bron- fl oor later to be followed in clinic. Further- chiolitis very differently than a one-year-old more, there is no repetition of place-names with bronchiolitis. Infants, and in particular within the history.
prematurely born children, are vulnerable The different indexical centering of place to respiratory diseases and can quickly get names in the two document genres relate close- gravely sick and require intensive care as in ly to their temporal orientation. The trajectories Dylan and Annaʼs cases. A toddler admitted sketched in the Senior Note are a temporal or- with bronchiolitis typically stays only a few ganization of places and participants. In other days. The exact age does not seem to matter words, the Senior Note characterizes the rela- a great deal as one often fi nds variation in tionship between physicians and their object the age reported. We notice that the senior of reference as temporally organized around note reports Dylan and Annaʼs ages as one a sequence of locations involving different month and fi ve weeks respectively whereas participants. In contrast, the HOSO offers a the HOSO gives Dylanʼs age as 43 days, and here and now framing of the relation among Annaʼs as two months.
participants, places, and patient. To better We fi nd another set of temporal references understand those differences in the indexical in the body of the histories. Marcʼs HOSO in- centering of the patient histories let us elabor- cludes dates under the sections, problems and ate the structure of temporal references used procedures. This builds a temporal fi eld where in the two genres.
the date of a procedure, the beginning and end of a problem is the paramount issue at hand. Temporal references in the patient history What matters to the interns are when a problem We fi nd three main types of temporal refer- started, or rather was diagnosed, and whether ences in the HOSO and Senior Notes: dates, the problem has been resolved. What happens temporal deictics (e.g., now, recently, current- in between does not seem to be essential in the ly), and references to the frequency of specifi c context of the HOSO. The Senior Notes does activities (e.g., how often to administrate medi- not demarcate quite as narrow a temporal fi eld. cation). The header of both HOSO and Senior Dylan and Annaʼs histories contain the dates Notes summarize Dylan and Annaʼs admission of several important events. For instance, we date and their age. The admission date plays an learn that Anna was transported from Com- important role in patient care as it pertains to mon Hospital on January 29, intubated in the the reimbursement and the physiciansʼ general ICU between January 29 and February 12, and sentiment of how long time a patient should transferred to the fl oor (i.e., 10 East) on Febru- be in the hospital given the severity of his or ary 15. Likewise, the senior history provides her ailment. Frequently, a senior resident or the dates for a number of different events such attending doctor will state some variation of as the discontinuation of some of her medica- the following comment during morning rounds tion on February 11. In comparison, the HOSO from: "This kid has been here for more than only provides the names of medication cur- a week. We need to get him rolling." Trans- lated this means that the intern should start If we introduce temporal deictics into our working hard on getting the patient ready for analysis of the Senior Notes we fi nd that each paragraph builds around a past-present struc- Dylan and Annaʼs age can be found just ture. Consider the GI section where I have 40878_outlines 2003 nr2 63 3/31/04, 14:51:12 Carsten S. Østerlund • Documenting Practices
highlighted the temporal deictics, "when" valuable to specify the temporal structure of and "now." Comparable to Dylanʼs case, Annaʼs HOSO GI: On NJ continuous feeds when transferred from history provides a snapshot of the current state ICU. Now on po feeds.
of affairs: Her respiratory distress and bron- The excerpt follows a past-present structure chiolitis are considered cured on todayʼs date – explaining that Anna received nutrition and she receives only medication if needed through a tube at the time she was transferred (i.e., PRN). Annaʼs HOSO history is a signal to from the ICU to 10 East. Now the tube has Marc and his fellow interns that Anna is ready been removed and she gets her food by mouth. to go home and that she requires little if any Most of the other paragraphs follow the same medical attention. Dylan, in contrast, calls for structure. The fi rst part of the paragraph sum- signifi cantly more involvement and collabor- marizes a number of past events and/or test ation with several different subspecialties.
results; a date or temporal deictic typically specifying the timing of the event. The sec- Conclusion: Maps &
tion closes with a description of the current
state of affairs, for instance: "now on room itineraries
air;" or "currently stable."
The HOSO and Senior Note contain many Dylanʼs and Annaʼs histories in the HOSO common features and references to participants contain only one such example. In line 12 Dy- and their relations to patients. Nevertheless, lanʼs entire hospital trajectory is summarized our analysis reveals important variations in in one sentence. The remaining sections simply the indexical centering of the two genres. The recap the current state of affairs. We learn noth- HOSO builds an indexical ground that offers a ing about past medication or test results. The here-and-now discursive fi eld for a small group only other temporal reference we fi nd in Dy- of interns working closely together on a day-to- lanʼs HOSO history is the frequency by which day basis. The HOSO does not concern itself his medication should be given. Even this is with a description of past places and events. not spelled out very carefully. We learn that he It emphasizes the current tasks at hand. Much should be given Racemic Epinephrine "when like an itinerary the HOSO outlines the dayʼs needed" (i.e. PRN). We do not learn how often activities facing Marc and his colleagues. The he should get Azihromycin – only that it should interns have relatively symmetrical access to be given for fi ve days. The Senior Notes tend to the knowledge about Anna and Dylan and their be more specifi c, as for instance, in line 16 of past medical history. Every morning they listen Dylanʼs history: "Started Prosobee at 5cc/hr." to short summaries on their histories.
Given that the interns are responsible for The interns work in the same team on four patientsʼ medication one might expect that to fi ve week rotations. Their collabor ators they would record the dose and frequency and the departments where their patients are more carefully in their notes. However, the admitted change constantly. Yet, the basic interns use a separate order sheet and medi- setup remains constant. In contrast, the senior cation chart for this specifi c purpose, which residentsʼ "playing fi eld" can change within also serves as a means of communication with one workday when they go from their day the nurses. In other words, giving too much work in e.g. Pediatric Team B to covering detail on medication in the HOSO would lead for other senior residentsʼ teams at night. The to needless repetition. The senior residents do senior residents do not share the same degree not use the order sheets, so to them it becomes of symmetrical access to their object of refer- 40878_outlines 2003 nr2 64 3/31/04, 14:51:14 Outlines • No. 2 • 2003
ence, the patients. Elisabeth knows a great deal Returning to the questions posed in the in- about Dylan and Anna, which she shares with troduction, we can now argue that Marc and Marc and the other interns. But, at night she Elisabeth use different documenting genres as covers for other senior residents and must care they support differently confi gured fi elds of for patients she knows little or nothing about. relations to collaborators and patients. Each While the interns have a high degree of access document genre builds an indexical ground to each other and a symmetrical access to their unique to the specifi c user group. First, these object of reference, the senior residents have two collective on-line documents summarize neither. They do not work shoulder to shoulder two different confi gurations of collaborators with the other senior residents during the day, and contemporaries working with an ever- and they do not see the same patients. With changing group of patients. Second, Elisabeth their Senior Notes, the senior residents build and Marc use the Senior Notes and the HOSO a fi nely marked indexical ground on which respectively, to demarcate the temporal and they can communicate about their patients. spatial structure of their communication prac-If we look at the fi rst dimension, the relation- tices. When do they have to meet with what ship between the interacting parties, the Senior people? The use of each document takes place Notes containing an explicit structure for the at certain time and places. Elisabeth and Marc senior residentsʼ current collaborators and the share their notes with a different set of col- temporal and spatial arrangements under which laborators at different times and places. Third, they work. In terms of the second dimension, the senior residents and interns build into their the relations between the interacting parties information systems indexical structures sup-and the patient, the object of reference, his- porting their unique work practices. The docu- tories take into account the lack of relevant menting practices involved in the production knowledge about patients like Dylan and and use of the HOSO and Senior Note help Anna. To account for this lack of symmetri- the interns and senior residents structure where cal knowledge the history builds an indexical they need to go within the hospital, and in rela- context that specifi es the times and places of tion to what collaborators and patients.
the patientʼs past and present care, tests results, Those documenting practices structure their medication, etc. To one of Elisabethʼs fellow use of both time and place. At night Elisabeth senior residents on call at night Annaʼs HOSO typically attends to other patients than Marc history does not make much sense. The HOSO in different parts of the hospital, subjects to stands out as opaque – maybe even misleading. different temporal rhythms. Furthermore, the Apart from Elisabeth, the senior residents do two groups do not focus on the same aspects of not know what Marc and three other interns care. The interns carry out the scut work, and know – that Anna, despite the horrible hospital the HOSO gives the times and places where trajectory she has been going through the past tests should be taken, procedures preformed few weeks, is set to go home to her mother and and patients seen. The senior residents do not father in a day or two. To them Annaʼs history go into the same details of care, and their Sen- in the HOSO reads as a patient who has recov- ior Notes refl ect this in the indexical centering ered from her bronchiolitis and requires little of the patient histories. In short, the Senior if any attention. On Marcʼs part, why should Notes and HOSO serve two groups requiring he spend valuable time dissecting the Senior different mapping of relationships and itinerar- Note to fi gure out what the current status of ies for work practices. As itiner aries the two Annaʼs case is when he can simply glance at document genres are more than mere lists. The the HOSO and go to work? HOSO and Senior Note do not solely map out 40878_outlines 2003 nr2 65 3/31/04, 14:51:15 Carsten S. Østerlund • Documenting Practices
the stable positions among the different inter- the formal and the informal – the abstract and acting parties and their objects of reference. the situated.
As itineraries they take time and movement Hanks comes to our rescue. He offers a into consideration. In de Certeauʼs words (de comprehensive framework demonstrating how Certeau, 1984), the itineraries take into con- abstract and formal deictic systems embedded sideration vectors of direction, vel ocities, and in linguistic code allow us to situate our every- time variables. Each itinerary allows a group day communicative practices. To put it differ- to move in a fi eld of interrelated mobile ele- ently, the indexical elements embedded in the formal structure of language serve as resources The importance of a document genreʼs in- for our evolving practices. They let us situate dexical centering may explain why the fi eld our practices in complex organizational struc- of medical informatics has not succeeded in tures. Through their everyday practices Marc implementing global patient-centered medical and Elisabeth build indexical fi elds that permit record systems. Such large-scale systems do them to situate their practices across time and not allow their users to tailor an indexical fi eld many different organizational units involving for their interaction. Physiciansʼ resistance to an ever changing group of participants.
medical informatics, then, cannot be explained Those linguistic structures embedded in by a general technophobia among doctors, as their document genres are windows into the many researches assume, but simply that phy- unfolding dynamics of their everyday work sicians (and nurses) do not like when some- practices and their particular position in body messes with the details of their daily itin- eraries and takes away their ability to fi ne-tune The Hanks inspired analysis points to a their collaboration and knowledge sharing with double nature of documenting practices in specifi c constituencies of colleagues.
relation to the doctorsʼ general practices. At this point one could conveniently slip First, Elisabeth and Marc produce and use the into a polarizing position claiming that all Senior Notes and HOSO as part of their daily there exists is situated knowledge embedded communicative practices. The two document in the richness of the empirical world. This genres index these ongoing communicative opposing position would argue that a patient- practices: Who writes what documents? When centered record which attempts to abstract a do they do it? Where to they do it? When globally meaningful patient history is all but an and where do they use those documents to impoverished version of the rich and textured structure their discussions about patients? For situated knowledge held by local participants. instance, the fi rst part of the Senior Notes out- However, as Berg (1997a) argues, both posi- lines a rudimentary timetable for the produc- tions picture the realm of the abstract and for- tion and use of the document and a list of the mal as hovering above the realm of the empir- places and people involved in those document- ical everyday world. "The formal is symbolic, ing prac tices. Second, Elisabeth and Marc also clean, abstract, homogeneous; the empirical is compose and use the Senior Notes and HOSO messy, heterogeneous, concrete and not (to be) to communicate about their ongoing care prac- ordered within one single scheme" (ibid.: 406). tices. The HOSO index the involved partici- One is the global patient-centered record; the pants in their daily work whether patients other is the lived experience of patients, nurses, or doctors and nurses. They also demarcate and doctors. Berg (ibid.), Markussen (1994), the tem poral and spatial structure of those and Star (1995) among others call for recon- practices. In what departments does Marc fi guring this dichotomous opposition between have patients at the moment? Where are the 40878_outlines 2003 nr2 66 3/31/04, 14:51:17 Outlines • No. 2 • 2003
other collaborators located? What timeframe general approach to communicative practices guide the care? In short, we can argue that the will inform our approach to knowledge sharing composition and use of the HOSO and Senior in organizations and the way information sys- Notes allow Elisabeth and Marc to build an in- tems support such practices. Equally important, dexical structure highlighting the "who, when, such a focus would allow us to re-conceive the and where" of their communicative practices dream of the universal patient-centered record and their general care practices. Documents and help the fi eld of medical informatics build are both in and about practice. They are both systems that better serve doctorsʼ and nursesʼ situated and situating. The documents simul- daily care for patients and the organizational taneously make references to and articulate realities they face.
with the context in which the reference is performed.
With the notion of indexical centering in hand we do not have to perceive situated know- Bakhtin, M. M. (1986). "The Problem of Speech ledge as merely context-bound. The indexical Genres." In Speech Genres and Other Late structures we fi nd in the HOSO and Senior Essays: M. M. Bakhtin, C. Emerson and M. Holquist (ed.), pp. 60-102. Austin: University Notes demonstrate that physical boundaries of Texas Press.
such as an inpatient unit or the emergency Berg, M. (1997a). "Of Forms, Containers, and the room do not defi ne the situated fi eld within Electronic Medical Record: Some Tools for a which Marc and Elisabeth operate. The two Sociology of the Formal." Science, Technology, doctors use their documenting practices to & Human Value 22: 403-33.
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centering comparable to the HOSO. In short, I believe that a further refi nement of Hanksʼ 40878_outlines 2003 nr2 67 3/31/04, 14:51:19 Carsten S. Østerlund • Documenting Practices
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40878_outlines 2003 nr2 68 3/31/04, 14:51:21

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SAFE MEDICATION PRACTICES HIV Postexposure Prophylaxis and the Need for Drug Interaction Screening Roger Cheng, Julie Greenall, Christine Koczmara, and Sylvia Hyland Contributions to this column are prepared by the Institute for Safe Medication Practices Canada (ISMPCanada), a key partner in the Canadian Medication Incident and Prevention System, and include, withpermission, material from the ISMP Canada Safety Bulletin. The present article is based on "Drug interaction incident with HIV post-exposure prophylaxis", ISMP Can Saf Bull 2008;8(3):1-2. From time totime, ISMP Canada invites others to share learning based on local initiatives.