Social Interactions That Influence the Preparation of the Clinical Record and the Communication of Information During Medical Care

Abstract

The communication of health information guarantees the continuity of care, however, there are social interactions that emerge due to work conditions that affect this communication, generating a discontinuity of care. The objective of the study was to recognize the social interactions that affect the communication of health information from the Clinical Record, during medical care. The methodology used was the case study, the extended case method, ethnography and narrative interview in a second level public hospital in Mexico City. The results show that emerging social interactions depend on the scarce digital infrastructure and work overload, affecting the communication of health information in the Clinical Record. In the discussion, it was interpreted that doctors perform alternative actions such as the use of personal resources and the preparation of informal clinical records to try to make the best clinical decisions.