Documentation and naming

Emma Williamson

in Domestic violence and health

Published by Policy Press

Published in print December 2000 | ISBN: 9781861342157
Published online March 2012 | e-ISBN: 9781447302148 | DOI:
Documentation and naming

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This chapter deals with the issue of documentation, which was an area of concern in the stage-one interviews. Examining the issues of culpability, documentation, confidentiality, and the medical record is important, as it is through the written patient record that medical complaints become integrated in medical discourse, through research and the acknowledgement of clinical practice. There are a number of issues that relate both directly and indirectly to the use of medical records, including: the use of medical records in training; legal discourses; as an event itself within the medical encounter; as representative of the hierarchy which exists between different healthcare professionals; naming; recording; and the appropriation of the sick role.

Keywords: medical record; legal document; documentation; medical encounter; confidentiality; sick role

Chapter.  5439 words. 

Subjects: Marriage and the Family

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