Charting the Chart—An Exercise in Interpretation(s)

^Charting the Chart—An Exercise in Interpretation(s) Suzanne Poirier, Lorie Rosenblum, Lioness Ayres, Daniel J. Brauner, Barbara F. Sharf, and Ann Folwell Stanford The multiauthored article is standard in the medical sciences, where the politics of the laboratory and the academy often loom larger than the singularity of the argument or grace of its execution. The following paper, however, depends upon the singularity of each of its authors and hails the individual grace of their arguments. Although collaborative, this paper is primarily collective, composed of unique readings of the same document. In its array of individual viewpoints and interpretations, it underscores the collective nature of the entries that constitute the single entity identified as the chart. As the record of one patient's hospitalization is really a diverse collection of individual voices as well as professional interactions or viewpoints, so the responses of these readers are unique to each one's personal and professional backgrounds.1 —Suzanne Poirier, Ph.D., Literature2 Contexts The medical record3 treated in this essay is that of a sixty-nineyear -old black woman who, after treatment for a stroke in the acute hospital, was admitted to a rehabilitation facility for approximately two months. This particular facility is designed for patients over sixty who are able to tolerate up to six hours of intensive physical and occupational, and, if needed, speech therapy a day. The rehabilitation setting utilizes an interdisciplinary team consisting of the physical medicine and rehabilitation physician, the primary nurse, physical and occupational therapists , speech therapist, recreation therapist, chaplain, psychologist, and social worker. AU of these professionals meet regularly, both formally and informally, in an extensive network of communication. Because this Literature and Medicine 11, no. 1 (Spring 1992) 1-22 O 1992 by The Johns Hopkins University Press CHARTING THE CHART is a rehabilitation unit, the team's focus is on activity: the patient's medical condition is presumably stabilized, and the goal of the treatment is to restore as much as possible the patient's functional abilities, and to return the patient to the community. The original outcome predicted for this patient, whom we shall call Mrs. R, was that she would recover sufficiently to return home and resume life with her ailing husband. She would need the support of neighbors and a niece and the addition to the household of a Department of Aging homemaker twenty hours a week, the maximum that the state will subsidize. During the course of treatment, however, it was discovered that the family situation was more problematic than was first apparent and that the patient was more seriously impaired than was first thought. In short, the husband was not only ailing, but had a history of alcoholism that contributed to a conflicted relationship between the spouses; the patient herself needed hands-on assistance in order to transfer from bed to chair to toilet, and so forth; friends and relatives could not or would not assume the burden of care; the family could not afford twenty-four-hour nursing care, and the twenty hours a week offered by the state was insufficient. Clearly, the patient could not return to her home and would have to be placed in a nursing home, an outcome which was, in terms of the team's efforts and goals, an appropriate disposition, but was for this patient anathema, and a confirmation of her worst fears. After a certain point, then, the team's efforts were concentrated on helping the patient "adjust" to this intolerable situation and on dealing with her expressions of despair. Printed below are two sections from Mrs. R's chart, one from early in her hospitalization and the other near the end of her stay. The sections provide a sample of some of the many health professionals writing in Mrs. R's chart and convey the shift in the story from the hope of Mrs. R and all her caregivers that she would return home to the growing realization on the part of Mrs. R that her hope had been denied. The subsequent commentaries each focus on one of the characters or voices heard in the chart: the patient, the nurse, the physician, the social worker, and the...