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Related Experiment Videos

Voices in the record.

J C Hays

    Image--The Journal of Nursing Scholarship
    |January 1, 1989
    PubMed
    Summary
    This summary is machine-generated.

    Nursing documentation, or charting, often follows a rigid approach. This study proposes using "discourse" to better understand the political and professional dynamics of recording patient care, advocating for more flexible methods.

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    Area of Science:

    • Nursing Informatics
    • Healthcare Documentation
    • Sociology of Professions

    Background:

    • Nursing documentation (charting) is central to professional practice but often treated mechanistically.
    • Existing literature, education, and institutions present a 'cookbook approach' to charting.
    • Historical controversies surrounding home care records highlight underlying issues.

    Purpose of the Study:

    • To propose 'discourse' as a conceptual framework for analyzing nursing documentation.
    • To explore the political and professional dynamics inherent in the recording process.
    • To advocate for innovative documentation methods reflecting diverse perspectives and complex patient care realities.

    Main Methods:

    • Historical analysis of controversies surrounding the home care record since the nineteenth century.

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  • Application of discourse theory to understand the social and political context of charting.
  • Critical examination of current documentation practices in nursing.

    • Main Results:

    • The 'cookbook approach' to charting fails to capture the complexity of nursing practice.
    • Discourse analysis reveals significant political and professional influences on documentation.
    • Historical examination shows persistent challenges in representing patient care accurately.

    Conclusions:

    • Rethinking nursing documentation through the lens of discourse is essential.
    • New documentation strategies are needed to embrace the 'fellowship of discourse'.
    • Modern patient care requires documentation that reflects its complex and diverse reality.