The Living Document: Medical Records as a Malleable Presence

Understanding why individuals might safeguard information or keep secrets in working documents such as medical records is essential for the development of good quality care, fostering an environment where both patients and staff feel secure to part with sensitive information, encouraging more honest and open communication as well as improved quality of care. This ongoing research aims to deepen comprehension of information behavior in clinical contexts, where the contemporary medical record, with its increasing properties such as open record access for patients, can be viewed as an entity that both listens and influences. This examination sheds light on the complex dynamics of truth within clinical environments, where patients and health care professionals, due to a continuously evolving document, might selectively disclose or withhold information, aiming to safeguard themselves. Fifteen informant interviews among Swedish clinicians in pediatric psychiatry concerning the impact of open record access reveal that the contemporary medical record takes on a form reminiscent of a malleable presence, embodying qualities of a sentient being within the treatment space. Findings in the study shed light on the intricate mechanisms through which the protection of both information, patient, and clinician, intertwine with the contemporary medical record as an entity of great agency.