In June I graduated from The Swedish language consultancy programme (Språkkonsultprogrammet). My bachelor thesis is a part of the research in the Hexanord-project. The thesis is written in Swedish and the title is Patientjournalen som genre (Patient records: a genre analysis).
The topic of the thesis is the language in patient records. The aim was to examine how well the law (Patientdatalagen/Patient data act) corresponds with the reality, and what the writers, medical doctors, think about the law. My special interest was paragraph 13 that says “the patient records should be as easy as possible for the patient to read”.
I also examined if parts of the records might be hard to understand if you are neither a doctor nor a nurse. A textual analysis, based on Hallidays sociocultural theories about language and grammar, was the main method in thesis. As a complement, a questionnaire was sent to doctors at Karolinska sjukhuset(/The Karolinska University Hospital). 40 doctors answered.
The results showed that the records can be difficult at several levels. They contain a lot of technical terms and abbreviations that even doctors might find difficult. The records are written from the doctors’ perspective. There are almost no people mentioned in the records. There are very few names and pronouns.
A majority of the doctors had a positive view on the law. A third of the doctors didn’t know of the law, and they were more negative than the others. Some of the doctors were highly set against the law, and emphasized that the medical record is first and foremost a tool, used by doctors and nurses in the care process.
The questionnaire showed that the doctors primarily write the record for their colleagues, and that they don’t write for the patients.
Patientjournalen som genre,pdf (in Swedish)