Functions of Medical Document “Clinical Record”

Abstract

The article is devoted to documentary linguistics, in particular to the functions of the medical document “clinical record”. The extensive medical documentation presence demonstrates not only the progress of science, but also the changes in the work of health professionals. The author gives the definition of this document as a verbal lay-out of doctors competences and their knowledge by fixing (with special professional signs) observations over the patients state in the form of texts which represent the specificity of disease treatment. The article provides the characteristics of the most significant peculiarities of speech representation in the document and the main functions informational, regulative, legal, logical, prognostic, and pragmatic. It was revealed that these features allow the physician to exercise professional competence and to contribute to the recovery of the patient. The functions of medical document reflect the purpose of this document patients recovery. The informational function is implemented through strict fixing the information, accuracy, standard forms of its verbal expression. The regulatory function is realized through an accurate description of the diagnosis and proves the ability of the document to control the cognitive activity of the doctor. The author believes that the clinical judgment of a doctor is realized through logic function. The argumentative function confirms the accuracy and clear form of the document. Logical and strict order of the sections indicates orienting and pragmatic functions.

Keywords

• documentary linguistics
• documentation
• medical document “clinical record”
• functions of the document
• information