Integrated care and the working record

By default, many discussions and specifications of electronic health records or integrated care records often conceptualise the record as a passive information repository. This paper presents data from a case study of work in a medical unit in a major metropolitan hospital. It shows how the clinicians tailored, re-presented and augmented clinical information to support their own roles in the delivery of care for individual patients. This is referred to as the working record, a set of complexly inter-related clinician-centred documents that are locally evolved, maintained and used to support delivery of care in conjunction with the more patient-centred chart that will be stored in the medical records department on the patient’s discharge. Implications are drawn for how an integrated care record could support the local tailorability and flexibility that underpins this working record and hence underpins practice.