Writing Medical Records

• Published in: Journal of technical writing and communication 1986-10, Vol.16 (4), p.331-341
• Main Authors: Pagano, Michael P., Mair, David
• Format: Article
• Language: English
• Subjects: Exact sciences and technology; Information and communication sciences; Information publishing, dissemination and reproduction; Information retrieval systems. Information and document management system; Information science. Documentation; Medical records; Medical students; Physicians; Questionnaires; Records (Forms); Sciences and techniques of general use; Scientific and technical writing; Technical communication; Writing
• ISSN: 0047-2816; 1541-3780
• DOI: 10.2190/WY9T-634E-V2JT-JDVQ

A study was undertaken both to evaluate how medical students are taught to write patient records and to examine the writing done by doctors. Typical medical records, written by medical doctors, were also evaluated. A single questionnaire was sent to eighty-four medical school professors, twenty law school faculty, and five practicing attorneys. The questionnaire asked how medical records were used and what the legal implications were in authoring a patient record. The medical professionals were also asked how their schools taught medical writing. The questionnaire pointed out that most medical schools teach less than ten hours of medical writing in their curricula and that patient records are not written with an understanding of the various audiences, purposes, and uses for medical documents. Two radiology reports are discussed in terms of their clarity and usefulness for medical and extra-medical readers. The study concludes that medical students should be taught a composing process so that they will understand the audience, purpose, and use for the patient records they write.