Managing Information: Misrepresentation in the Patient's Notes
Published online on July 17, 2013
Abstract
Doctors are required to document their examinations of the patient. This task is particularly important in psychiatry, where what the patient says is practically the only source of information available to the clinician. In our article we shall focus on the process of information management in psychiatry and trace the information which was recorded in the patients’ notes back to its origin in the interview. Our data consists of eight recordings of psychiatric interviews along with the patients’ notes.
Our main argument is that the notes are not merely written from the point of view of the psychiatrist, but might have little or nothing to do with the interview. We demonstrate, first, that accurate notes are a record of how the doctor conducted the interview. Second, the notes doctors made also misrepresent the interview with the patient: doctors record false information, distort it, take out of its context.