Paper and people: the work of the casualty reception clerk.

This paper examines the exercise of discretion by casualty reception staff, focussing on the problems of accountability that arise when their judgements help shape the process of patient categorization that culminates in clinical diagnosis. Rules and guidelines which ostensibly relate to bureaucratic objectives, are applied in ways which reflect situational exigencies of reception work, and values embedded in organisational culture. But reception staff are reluctant to acknowledge the importance of their decisions, and, particularly where judgements relate to patient condition, present rule-use as a straightforward and certain activity in which interpretation plays little part.