Record keeping practices: Consequences of accounting demands in a public clinic

This observational study explores the tensions and negative consequences of record construction for patients and front-line staff in a public clinic providing services to poor women and children. For emphasis, it is possible to say that the routine of the clinic is record driven, not service driven. More is accomplished in clinic work than producing records; patients certainly do receive needed health care. However, tight regulations filtered through heavy paperwork requirements stifle the effective delivery of comprehensive, flexible services especially needed by disadvantaged families. Clinic staff may be motivated to attend to individual patient concerns, but accounting demands generally circumscribe their work and create barriers for patients. The record has a life of its own as a socially constructed artifact in the process of caregiving in bureaucratic settings, where actual services often respond not to the client, but to the countable, accountable mandates of management.