| The purpose of this dissertation is to describe, examine, and analyze the communication and rhetorical effectiveness of medical records. Twenty-five Histories and Physicals and 25 Discharge Summaries, written by 25 medical doctors, were obtained from 5 hospitals nationwide. A five point, Likert-type questionnaire was developed to evaluate the content of the 50 records. These questionnaires were completed by three evaluators, two medical doctors and myself. In addition, a second questionnaire was developed to evaluate the rhetorical effectiveness of the 50 records. A third questionnaire was created and sent to 50 medical doctors nationwide.;The results of the content analysis demonstrated that 70% of the 50 records did not contain all of the major sections described in medical textbooks, federal guidelines, and JCAHO regulations. In addition, 18 percent of these records did not communicate sufficient information for the three evaluators to reach the same diagnoses as the records' physician-authors. Furthermore, the documents did not rhetorically communicate information that demonstrated the physician-writers' professional competency and credibility.;Fifty-five percent of the questionnaires sent to medical doctors nationwide were completed and returned. Seventy-six percent of the responding physician-writers reported an increase in the amount of information they document in medical records because of DRG and PRO reviewers. But at the same time, 81% of the respondents describe undertaking such a difficult task with no formal training in writing medical records.;The microanalyses of the 50 records demonstrates numerous semantic, syntax, and editing errors. These signed legal documents contain so many grammatical, semantic, and editing mistakes that they are frequently confusing, uninformative, and potential liabilities for their physician-authors.;The results of this study clearly support the need for teaching formal writing courses in American medical schools. These 50 medical records illustrate the importance of educating physician-writers about rhetorical effectiveness and its value to both readers and authors. This research further attests to the need for more quantitative ad qualitative studies of medical records. The findings in this dissertation reveal that a vital form of healthcare communication, the medical record, is seldom researched, infrequently taught, and consequently, poorly authored. |
