Results:
Observation of HP’s recording of social data showed up its inadequacies. In the following, we present the results. Having accounted for the arbitrary nature of HP’s registration of patients´ social histories we outline the organizational and professional barriers to recording patients’ social circumstances. We use D in citations for ‘doctors’ and N for ‘nurses’. Table three provides an overview of themes and subthemes.
Arbitrary registration
During observations, we examined HP’s prior knowledge about patients’ social background. If HPs, especially doctors, did register social data, they did not do so systematically and seldom knew about patients’ social status or background. Furthermore, if asked about a patient’s social background, doctors were often unable to find information in the medical record since it might not have been entered. Moreover, if the medical record included social data, it was rarely precise. For example, records might describe patients as a ‘senior citizen’ (fieldnotes) without specifying the nature of their profession.
Doctors and nurses registered medical information about patients in their respective digital records, often ‘visiting’ them to check medical information. While they claimed to prefer sharing social information about patients at medical conferences, observation showed that this was not routine. If patients’ social circumstances were brought up, this mainly occurred in extraordinary cases such as severe alcohol abuse, homelessness or lack of compliance.
Nonetheless, the medical record did usually indicate whether the patient or the nearest companions were qualified healthcare professionals, suggesting a need to be extra well-prepared to answer any medical question. HPs sometimes searched for social information in the medical record if communication with a patient was difficult, hoping that this would facilitate communication. However, attempts to record and access information about patients’ social circumstances were unstructured.