The notion of a genre system typically connotes sequences of interrelated communicative genres. This paper suggests that we can find other types of relationships among genres. Data from a field study in a large emergency room illustrate how doctors, nurses, and clerical staff routinely combine document genres not only in sequences but also in various accumulations achieved through proximity and movement. The combinations of genres add flexibility to the emergency room staff's genre use and allow them to employ individual genres for several purposes. The data allow us to explore how organizational members manage the tension between a need for continuity in communicative practices and a need for flexibility in managing a jumble of paper-based and digital information systems. In addition, it demonstrates how end users often tinker with genres' media and form in the process of altering combinations among specific genres.