Charting, Rhetoric, and Technical Communication: Primary-Care Progress Notes in Rural Oregon

Abstract

Medical documentation--i.e., charting--is widely known to be crucial for patient care, billing, and legal protection, but it is simultaneously largely viewed as tedious, time-consuming busywork that takes clinicians away from patients, especially in the era of electronic health records (EHRs). There has been excellent but limited research on how writing skills (and thus, explicit writing instruction) influence both the charting experience and charting outcomes (Schryer, 1993; Opel & Hart-Davidson, 2019). In this project, I investigate how progress notes within EHRs could be improved if medical providers had more training in rhetoric and technical writing. Specifically, I focus on primary care, as primary-care providers have been shown to spend the most time on EHRs (Rotenstein et al, 2023). I draw upon a corpus of de-identified primary-care progress notes and the insights of primary-care providers, both sourced from clinics in rural Oregon. My major conclusions are that primary-care providers would benefit from being taught how to write with attention to audience and purpose and that rhetoricians of health and medicine have an opportunity to help improve patient charting.