The medical record as organizing discourse

This paper analyzes different manifestations of the medical record in order to demonstrate how and why some discourse creates greater organizational reach. In doing so, the paper presents four arguments. First, that types of discourse research that analyze organization from the perspective of regularized practices on the one hand, and those which frame organization as narrative and story-telling unfoldings on the other, are to be complemented with discourse research that considers the inherent characteristics of discourse and its relationship to and relevance for organizational process. Second, that organizing discourse is discourse that mediates between specifying and dedifferentiating moments of representation, by interposing standardizing categories, inscriptions and material appearances; only in this way is discourse able to connect the specific and the personalized with the general, abstract, and depersonalized. Third, the paper argues that the paperbased medical record largely absolves clinicians from ‘organizing’ clinical care as it is defined in this paper: its discourse (content, visual appearance, rules governing authorship) remains ‘un-organizing’. Finally, it is argued that the electronic PCIS is being framed in discourse that standardizes how clinical care is informated, and potentially even intervenes in the substance of that care; and while at greater risk of bringing about ‘bad records’ (Garfinkel 1967), such ‘organizing discourse’ ultimately achieves ‘lines of force’ across and beyond the clinic.