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  • Title: Working off the record: physicians' and nurses' transformations of electronic patient record-based patient information.
    Author: Varpio L, Schryer CF, Lehoux P, Lingard L.
    Journal: Acad Med; 2006 Oct; 81(10 Suppl):S35-9. PubMed ID: 17001131.
    Abstract:
    BACKGROUND: Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training. METHOD: Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric. RESULTS: Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum. CONCLUSIONS: This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR's visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential.
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