# Narrative vs entire PCR



## lacey15890 (Nov 21, 2018)

What info goes where? What info should be repeated if any? please lay this out for me


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## DesertMedic66 (Nov 21, 2018)

Every company is going to have different standards and each provider will say different things. For my ground agency (flight company doesn't really use narratives) I just label things out in chronological order from how the call started to how it ended. I try not to repeat information that is in other parts of my PCR but will include them if they are relevant (vitals, medical history, allergies, treatments). The way my current ground company is I can pretty much do a full PCR with no narrative and all the relevant information will be there for QA/QI, billing, hospital reference, etc.


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## Peak (Nov 21, 2018)

It depends largely on your service and what you are trying to accomplish. 

Even back when I was in fire we didn't really care that much if our billing got rejected so we didn't worry that much about it, we were more concerned with having a good medico-legal record of the call. They did want us to document individual procedures, assessments, medications, and so on for easier identification for the billing people. We also outsourced all of our billing to a 3rd party since we would rather have lost some of our money than face legal or financial repercussions. 

If I'm riding a specialty transport to or from the hospital I'm just there to provide care that the transporting agency can't (for ALS crews typically given blood or managing multiple pressors; CCT is typically for monitoring congenital hearts), and we consider it to be an extension of their care from the hospital so I just write a note in their hospital chart; we don't bill for this service so it doesn't really matter as long as I have good documentation of my care.

When I'm actually in the field I just write a SOAP note and re-evaluations and needed, we don't bill so all of our clinicians write up their charts a bit differently.

Our actual CCT/HEMS group documents almost everything in timed events rather than as a narrative, it helps to defend their billing and these transports are typically higher risk from a legal perspective so it provides a much better record if/when they get called into court. There is almost no narrative to their charting, at most 2-3 sentences for something that just didn't have a event that could be documented under.  

I would strongly recommend against any duplicate charting, any information that doesn't match up perfectly is a huge opportunity to be torn apart in court or for reimbursement rejections.


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## NomadicMedic (Nov 22, 2018)

I disagree with almost everything written above. As someone who deals with documentation compliance on the regular, here’s a couple of basics that you can pass on to your crews. 

All of the info that is listed in a drop down, check box or entered in the flowchart is there as a trigger. It’s either there to trip a QM flag, accountability, NEMSIS tracking item or as a reminder to add it to the narrative. The narrative is the important part. 

It’s vital to paint a good clinical picture of each encounter in the narrative. Do not let your providers get away from documenting details by saying, “treatment per protocol” or “see flowchart”. The narrative should be a complete accounting of the entire patient contact. Lack of narrative is FAR more difficult to defend than a solid descriptive narrative. 

As far as duplication of info, Steve Wirth said it best, “if your providers are worried about making mistakes in double documentation, they are working in the wrong field”.


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## Flying (Nov 22, 2018)

My narrative often ends up repeating some information from previous forms filled in the chart. I generally end up either matching or expounding upon the past info and then catch any discrepancies with a double/triple check when finishing. So far, there have been no issues raised by any billing/QA/legal entities.

When it comes to whether or not specific info should be repeated, I don't really mind it. I see the narrative solely as a detailed description of what I've seen and have done, other forms shouldn't really have a bearing on it.


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## NomadicMedic (Nov 22, 2018)

Exactly right. Your narrative doesn’t necessarily have to have routine drug dosages listed but should include the salient points of the care.  For example, it is entirely appropriate to document that you administered 40mcg of Epinephrine 1:100 in 10mcg aliquots for your hypotensive patient. 

Most EMTs and medics dramatically under document their care.


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## Peak (Nov 22, 2018)

NomadicMedic said:


> I disagree with almost everything written above. As someone who deals with documentation compliance on the regular, here’s a couple of basics that you can pass on to your crews. ... As far as duplication of info, Steve Wirth said it best, “if your providers are worried about making mistakes in double documentation, they are working in the wrong field”.



You can paint a good clinical picture without duplicating your charting. Unfortunately charting has become more and more about how to get reimbursement rather than a good medico-legal record of the patient encounter. I can't tell you how much fluff is in every report that companies fax to us. We also get quite a few transports in where there were real practice issues that we need to address with medical directors, and the charting they send is completely useless and neither reflects the patients care as they gave in report nor the real reason the patient was being transported anyway. Our EMS phones are recorded and we save the recordings both for QC and legal defense, and its shocking how many EMS phone reports aren't even close to what they chart in their records. 

For the record I don't have a problem with actual duplication. Some of our Docs will copy and paste RN event notes into their notes because they feel it helps them paint a better picture of the care, I think that it is redundant and unnecessary but I don't actually care. The problem is when errors arise because duplication isn't perfect. When clinicians report that the patient denies pain but then documents a subjective pain score at the same time in a flow sheet, when they document NSR in their note but their only rhythm strip or 12 lead shows a different rhythm, when they document that the patient was hypoxic even though they are in goal saturation given their medical history and didn't do anything to address their documented concern for hypoxia. I've had to ride transports where we get a fax of the run afterwards and seen all kinds of documentation of care that never actually happened or didn't reflect upon the actual patient condition. 

If you really want to know why we lose cases ask you insurance company, I wouldn't leave my charts open just from a lecture from a lawyer who I can almost guarantee started his presentation with some kind of slide or statement that it wasn't formal legal advice. And honestly, unless he is providing formal legal counsel it doesn't really matter to him if you go to court or not, it is easy to say that lawsuits happen and don't worry but its another thing to actually defend a case. There are plenty of studies by physicians who went to court and won but still found the experience so devastating that they quit their practice. I've fortunately never had a case go to court, but I've had plenty of cases pulled by legal/risk management/ethics/compliance/M&M; those are times that the hospital or medical practice is on our side and it is still a horrible experience. 

Long story short: Don't get pulled to court, but if you do make sure your charting accurately defends you patient care. Not only are your clinicians at risk but they can certainly go after your service as well.


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## DrParasite (Nov 22, 2018)

I don't duplicate anything in a checkbox on my narrative, unless there is a really good reason to.  This typically means super abnormal findings, justifications for why I gave a medication, or anything that I think will need further paints of a picture 5 years from now.

If anyone ever says something isn't documented in the narrative, all you need to do is show them that it's documented in a checkbox.  If you want to duplicate everything you put on your check box in your narrative, go nuts, but as @Peak said, when conflicting information occurs, you're going to have a hard time defending what you wrote.

and besides, you can be called into court (and lose) even if you have an amazingly written court, especially if the attorney is good... and most are a lot better than paramedics think.  Even if you win, they will still make you look like an ignorant buffoon on the stand.

Anyone who tells you "if it isn't written down, it didn't happen" really got some bad advice, because this is one of those urban legends in EMS.  For example, I have NEVER written on a PCR that I transported a patient on the cot *with three buckles applied on the cot.*  That doesn't mean they weren't buckled; but I can swear with 100% certainty that if they were transported on the cot, they were buckled, or I would have documented an exception.  I also never documented "the patient wasn't sexually assaulted in the back of the truck"; that doesn't mean that because I didn't documented it as a negative, that I molested them in the back of the truck. See how that works?

BTW, @NomadicMedic , on the topic of Steve Wirth, you know what he considers the most important thing when an agency comes to him with a lawsuit?  nothing about documentation, he wants to know how long the crew was on scene with the patient.

@lacey15890 , speak to your billing company (or if your doing the billing internally, speak to your insurance company or some of your vendors) about what they want in the chart, and where, or hire a billing expert or consultant.  If you want to know what needs to go where from a legal point of view, I would recommend you speak to your company's legal counsel.


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## Qulevrius (Nov 30, 2018)

lacey15890 said:


> What info goes where? What info should be repeated if any? please lay this out for me



As mentioned above, a clinical picture should be painted AND ea company will have its own standards. I’m using a template that I’ve developed years ago, and it never fails. It lists, in chronological order, the clinical findings starting with arrival on scene, paints a brief picture of the events leading to 911 activation, primary assessment + pertinent (+)/(-)’s, interventions, transport decision, reassessment en route + any clinically important changes, and ToC at destination. Some info is repeated for redundancy’s sake.


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## NomadicMedic (Nov 30, 2018)

I’m the QI manager and I make the decisions on our documentation standards. 

So, if you write a crummy, vague narrative or write things like “see flowchart” you get to spend some quality time with me.


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## Carlos Danger (Nov 30, 2018)

DrParasite said:


> Anyone who tells you "if it isn't written down, it didn't happen" really got some bad advice, because this is one of those urban legends in EMS.



This. Documentation by exception is used in every other area of healthcare and should be adopted by EMS as well.


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## NomadicMedic (Dec 1, 2018)

Really? For example, failing to document a blood glucose on a stroke patinet and then saying, "oh yeah, I measured it... I forgot to document it" is defensible?


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## PotatoMedic (Dec 1, 2018)

NomadicMedic said:


> Really? For example, failing to document a blood glucose on a stroke patinet and then saying, "oh yeah, I measured it... I forgot to document it" is defensible?


That isn't documentation by exception.  You only chart abnormal things.  So you would not chart strong radial pulses.  You would only chart the abnormal and assume everything is normal if otherwise undocumented.


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## Carlos Danger (Dec 1, 2018)

NomadicMedic said:


> Really? For example, failing to document a blood glucose on a stroke patinet and then saying, "oh yeah, I measured it... I forgot to document it" is defensible?


A BGS is an objective finding which is obviously pertinent to the assessment of someone with neuro changes. It would go in the objective part of the chart with the VS, EKG interpretation, IV location/size, IVF choice and rate, etc. If it is normal and doesn't require treatment, there's no reason to mention it anywhere else in the documentation.

With your charting system set up correctly (whether computerized or paper), it should be pretty difficult if not almost impossible to forget to chart something like a BGS in someone with neuro changes - it should be like forgetting to chart EKG findings in someone with a complaint of chest pain. In other words, BGS should be a field on your chart, and you should have to put a response in every field, even if it means writing or clicking "n/a".

But we're all human and we all occasionally find ways to screw up even well-designed things, so even if you did forget to chart a normal BGS somehow…….really, what are you worried about _defending_? You won't get in any trouble for failing to treat a normal BGS. Forgetting to chart or poorly charting an assessment finding is not the same thing as not performing the assessment. The only time failing to chart something gets you in trouble is if what you failed to chart also happens to be an assessment or intervention that was clinically indicated and can reasonably be expected to have prevented the patient's condition from deteriorating. So if you have what you think is a stroke patient and you treat them as such but never do a BGS, and you get them to the hospital and the ED finds that their BGS is 20, yeah, you'll probably have to answer for that. But what was really the problem - the fact that you didn't _chart_ a BGS, or the fact that you didn't _do_ a BGS?

I'm not defending lazy charting, I'm saying that failing to write a lot isn't what gets people in trouble. What gets people in trouble is bad care +/- bad charting.


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## Tigger (Dec 2, 2018)

NomadicMedic said:


> I disagree with almost everything written above. As someone who deals with documentation compliance on the regular, here’s a couple of basics that you can pass on to your crews.
> 
> All of the info that is listed in a drop down, check box or entered in the flowchart is there as a trigger. It’s either there to trip a QM flag, accountability, NEMSIS tracking item or as a reminder to add it to the narrative. The narrative is the important part.
> 
> ...


The duplication thing has been hit on at every finance education session I've attended over the last few years and the general trend that we have experienced is to justify treatments in the narrative but not necessarily add in doses or anything like that. As for documenting assessments, ESO has an entire assessment page. We are forbidden to document anything in the narrative regarding objective assessment and instead use that page. It has a multitude of drop downs as well space for notes for each system. This allows you to ensure you are not contradicting the boxes you have checked. 

I essentially write SAP notes in my narrative. The "P" is to summarize all activities that occurred throughout the call.


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## DrParasite (Dec 3, 2018)

NomadicMedic said:


> Really? For example, failing to document a blood glucose on a stroke patinet and then saying, "oh yeah, I measured it... I forgot to document it" is defensible?


BGL should be checked, along with every other vital sign, and documented as such.  Failing to document it would be on par with failing to do a stroke screen on a stroke patient; your defense of "well, it was normal, but not written down" probably wouldn't go over well, however on this stroke patient, did you check for pedal edema?  did you check for oral trauma?  did you check for rectal hemorrhaging?  did you document all these checks?  likely not, because it's unrelated to the patient's complaint, so we assume it's normal unless documented otherwise.

What are you defending, and who are you defending it to?  Yes, QA/QI might get a bug up their a** and ding you for not documenting a vital sign.  it happens, don't do it again, move on with life.  As Remi said, you don't document a BGL, say it's normal, and the ED gets 20..... now we have a problem, and you have no objective documentation to show exactly what the number is.  This is a problem.  Did you not check the patient's BGL, or did your glucometer malfunction (something I have seen happen once in my career, where the FD said the BGL was 110, and the ER got a result of 30 20 minutes later; they replaced that glucometer after an investigation).  Now if you have a negative patient outcome as a result of a "normal" finding that isn't documented, and investigators or lawyers get involved.......



Tigger said:


> The duplication thing has been hit on at every finance education session I've attended over the last few years and the general trend that we have experienced is to justify treatments in the narrative but not necessarily add in doses or anything like that.


For clarification, do the billing experts want you to duplicate document everyone, or only put it in one area to prevent contradictions?

I'm not defending poor documentation, but as someone who has reviewed some poorly written charts, and redesigned our agency's paper charts (before we went electronic), I can say I have seen some poorly written narratives, and seen people spend 15+ minutes writing their documentation on a refusal (this was after they left the patient's side, they were already on scene for 20), and at the end of the day, is it really needed?  Or more accurately, why are we documenting?  for an accurate record of the the patient interaction?  to defend against a lawsuit 7 years from today?  or to make it easier to bill?  It seems like the experts in all these areas would be a doctor, a lawyer, and a medical biller, and I don't know may people who wear all three of those hats teaching documentation classes.


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## Tigger (Dec 3, 2018)

DrParasite said:


> For clarification, do the billing experts want you to duplicate document everyone, or only put it in one area to prevent contradictions?


We were told to make sure treatments were included in the narrative as well as justification and response to them. However they stopped short of adding specific doses in the narrative. Billing people are much less concerned about documenting assessments it would seem. For me though, I am going to use the Assessment tab in ESO to document that, it is more thorough (for me) than typing it out and the generated report gives a whole page on the assessment if you use it that way.


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## NomadicMedic (Dec 4, 2018)

I think everyone needs to get out if the mindset of "I like to do it this way" and "it's better for me if I use this tab". 

Frankly,  as the QI person, I don't care what you write in the note section of the assessments or other tabs, as long as you write a complete chronology of your patient encounter.  It's not up to the individual provider to decide what goes in the chart. It's up to the provider to meet the documentation standard set by the service.  

We retain legal counsel and a consultant to advise us of best practices from a reimbursement and legal standpoint. Those are the standards we follow.


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## Carlos Danger (Dec 4, 2018)

NomadicMedic said:


> I think everyone needs to get out if the mindset of "I like to do it this way" and "it's better for me if I use this tab".


No one here has said this. Sorry you don't like the fact that others disagree with you, but that doesn't mean their motivations for thinking differently should be chalked up to laziness. 

You have to justify the care you provided in order to get paid for it, and you have to show that you followed the standard of care or acted in the patient's best interest in order to protect yourself legally. Neither of those things requires duplicative documentation or writing a novel. Everyone but EMS has figured that out. 



NomadicMedic said:


> We retain legal counsel and a consultant to advise us of best practices from a reimbursement and legal standpoint. Those are the standards we follow.


Fair enough. Just keep in mind that your lawyers and billing consultants probably have zero interest in the efficiency of your charting.


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## NomadicMedic (Dec 4, 2018)

I don’t mind if others disagree with me and at no point did I call anyone lazy. My statement was, the narrative is the most important part of your patient care report. Full stop. 

 Some of you choose not to believe that, which is fine. Your agencies may not believe that the narrative is the most important component of a patient care report, and that is also fine.  

And as for the efficiency  of charting, was Epic designed for efficiency or to maximize billing?


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## DrParasite (Dec 4, 2018)

NomadicMedic said:


> My statement was, the narrative is the most important part of your patient care report. Full stop.


Fair statement.  Ever use EMS charts at your agency?  they don't have a narrative.  anywhere.  at all.  Period.  So if something is that important, I would think that a popular EMS charting system would have included it in it's software package.





NomadicMedic said:


> Some of you choose not to believe that, which is fine. Your agencies may not believe that the narrative is the most important component of a patient care report, and that is also fine.


I know this wasn't your intent, but when you make that statement, and then back it up with your title as QI officer, you are pretty much saying everyone who disagrees with you is wrong, and you are right, using your title as backing up your claim.

Personally, I think your wrong, and I would ask anyone who says "the narrative is the most important part of the PCR" why aren't they looking at the entire PCR? No one section is more important, and each section by itself doesn't paint the entire picture. 

Electronic charting has changed the way we document, but some old timers continue to hold onto the classic concept that "everything needs to go in the narrative!!!"  We have more space to include information away (since a text field can hold unlimited information, compared to the old 3x5 box on the paper forms), and we can include more text boxes where you can put information.  Personally, I love documenting in the flowchart.  This is what I did, when I did it, what happened after I gave them something.  you can timeline much better than with a story.

Now if I am working for your agency, will you be pulling me into your office because my narratives aren't what you want?  probably.  And any information you ask that isn't in the narrative, my first response is "your right, but if you look up a little bit, you will see the information you are looking for in this check box, with the required information."  If it's not there, and it's medically relevant to this patient, and it's not documented anywhere else in the PCR, we might agree that you are correct that the information is missing.... but if it's not there, and not medically relevant to _this _patient, but would be relevant to other patients, then I am going to give you this example





DrParasite said:


> I also never documented "the patient wasn't sexually assaulted in the back of the truck"; that doesn't mean that because I didn't documented it as a negative, that I molested them in the back of the truck.


See what I mean?

Your agency might want a huge narrative with a lot of duplication of information.  And if I want to continue to work there, I will need to change my documentation habits to be what you want to see, or you will tell me to seek employment elsewhere.  But just cause you are telling me that the agency way is a full narrative, doesn't mean it's required, or even the most important. 

I will reiterate what I said previously:


DrParasite said:


> speak to your billing company (or if your doing the billing internally, speak to your insurance company or some of your vendors) about what they want in the chart, and where, or hire a billing expert or consultant.  If you want to know what needs to go where from a legal point of view, I would recommend you speak to your company's legal counsel.


I will also hypothesize that you can ask 3 different consultants for the best billing practices, and 3 different lawyers, and get 6 different opinions on what the best way to document would be.  Just something else to ponder.


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## Tigger (Dec 4, 2018)

NomadicMedic said:


> I think everyone needs to get out if the mindset of "I like to do it this way" and "it's better for me if I use this tab".
> 
> Frankly,  as the QI person, I don't care what you write in the note section of the assessments or other tabs, as long as you write a complete chronology of your patient encounter.  It's not up to the individual provider to decide what goes in the chart. It's up to the provider to meet the documentation standard set by the service.
> 
> We retain legal counsel and a consultant to advise us of best practices from a reimbursement and legal standpoint. Those are the standards we follow.


We will transition to the entire service no longer documenting any assessment in the narrative in January. I am personally a fan of that as I believe it gives you structure to allow you to be more thorough. That is only one reason we are changing to this format, it will reduce duplication errors and allow for more time spent describing the actual events of the call. I believe you use ESO as well, so what from a QI perspective is lost here? Our QI people (it's an ancillary job so I am not saying they are the most well versed), are very pleased with this transition.


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## DesertMedic66 (Dec 4, 2018)

If the narrative is the most important part of the whole chart, how does my flight agency (the biggest one in the nation) have a very robust QA/QI program, with a billing department and a legal department, with aggressive patient care guidelines operate with no narrative on our patient charts?


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## luke_31 (Dec 4, 2018)

DesertMedic66 said:


> If the narrative is the most important part of the whole chart, how does my flight agency (the biggest one in the nation) have a very robust QA/QI program, with a billing department and a legal department, with aggressive patient care guidelines operate with no narrative on our patient charts?


Heresy.  Burn the witch . Maybe, just maybe they have discovered the key... all that is written needs to only paint a picture of what was seen and done for the patient and a narrative is not the only answer.


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## DesertMedic66 (Dec 5, 2018)

luke_31 said:


> Heresy.  Burn the witch . Maybe, just maybe they have discovered the key... all that is written needs to only paint a picture of what was seen and done for the patient and a narrative is not the only answer.


Exactly. If all you have is a hammer, everything looks like a nail.


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## RocketMedic (Dec 6, 2018)

Narrative provides context. Would not be thrilled to lose it. Check boxes and comments often lack nuance.


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## Carlos Danger (Dec 6, 2018)

RocketMedic said:


> Narrative provides context. Would not be thrilled to lose it. Check boxes and comments often lack nuance.


True. I wouldn't want to lose it either. But you can write a brief narrative that describes the scene and how things went down without repeating all the objective info already documented elsewhere, and without writing a novel. Again, the idea that "the more your write, the better", is patently false. It's just more old EMS dogma.


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## Akulahawk (Dec 6, 2018)

As long as you can look at the report and determine the five "w's" of the call, and put it all in order from start to finish, it really doesn't matter what format you use. The important thing is to document accurately and completely enough so all that can be done and that you can therefore justify the care you provided. Remember, doing NOTHING is absolutely OK under the right circumstances and if you document it so that you can show that doing NOTHING was the appropriate care needed. Same for doing EVERYTHING. I don't double-chart whenever possible. It reduces the possibility that I mis-document a finding. If I charted that I found something on the right side and later forget and charted that I found it on the left... what else in my legal document might be wrong? I'm also a believer in charting (as much as practical) in real-time, or as close to it as possible. That way at the end of your time with the patient, you don't have much else to add to the chart and can close it out quickly.


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## JK773 (May 25, 2019)

I disagree with a lot that is written above. I am an EMT in MA for almost 8 years on a busy 911 service. I do about 100-125 calls a month myself and I can say I do not half *** any narratives. If your giving IM Epi, Narcan or Albuterol document your drug doses. Providing a BS narrative is only going to make you look like **** when you go in front of the judge. In MA our doc gives us a lot of play with our protocols. So there are no typos


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## CWATT (May 28, 2019)

NomadicMedic said:


> It’s vital to paint a good clinical picture of each encounter in the narrative.



This.  Someone once told me ‘you should be able to hand your PCR over so someone and have them arrive at the same conclusion you did’.  To achieve this, the narrative is essential.  I found the SOAP mnemonic obstructed my ability to ‘tell the story’ clearly.  SOAP requires the author to separate subjective from objective findings which causes the timeline to jump-around, and I’m honestly not sure what the benefit of this practice is anyway since your ‘assessment’ is objective but has its own section (for legal reasons, it’s easy enough to distinguish between the two anyway).  When I started working flight, that organization used the SBAR approach for patching which is essentially what I now use for charting:

Situation — also known as C/c.
E.g., 59 y/o male, C/P or 33 y/o Female Transfer from X-facility to Y-facility for blankety-blank

History — also known as ‘Background’; starting from the beginning, what happened up until you handed the patient off.
E.g., O/A to factory, male found slumped over in office chair, obvious distress, or O/A to hospital, pt found lying in bed, Ø distress, sleeping, vitals X, Y, Z on monitor, three infusions running.

On Exam (O/E) — also known as ‘Assessment’.  Now that you’ve told the story of who, what, when, where, why, how, and the reader has begun to formulate their own ‘game plan’, what were your examination findings.  This will vary slightly depending on the patient and their C/c, but for the most part it will include a systems approach where applicable (cardiovascular, respiratory, neuro.), physical assessment, and note any treatments already initiated (e.g., 20G L A/C fossa, lock).  I like to do one system fully then move on, so for neuro I might start with a GCS and continue through the full cranial nerve exam I performed before moving onto another system.

Treatments +/- Results — this is a bulleted section.  E.g., 50mcg Fentanyl IV @ 12:05 Pain 8/10 ∆ 4/10, or Ventilator freq. 18/min ∆ 16/min

It’s also important to recognize that you will also likely be limited to whatever PCR system you use (paper or ePCR) and may have to adjust your approach to meet the limitations or requirements of your system or specific expectations of your employer.


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## NomadicMedic (May 28, 2019)

I think whatever system you use is fine. SOAP, CHART or a simple chronological. 

What’s not okay is a narrative that reads like this:

“Responded to CP. PT CAOx3. VS as charted. Treatment in flowchart. PT XFER to ED.”

Yep. I’ve gotten charts like this.


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## Eli (May 29, 2019)

The first thing taught in law school is *never *write _anything_ down unless you have to. Why do you think lawyers teach each other that only to turn around and tell everyone else to write _everything_ down?

To the QA people writing all that hogwash about how a vague writer will find themselves in their office and crap like that. F the HELL off. You people are nothing but losers that get your jollys by telling your buds how you ruled the day telling so-n-so off. You are the personification of what makes EMS worse today than ever before. Do you really think your petty dictator power trips does anything to improve the efficiency and performance over what we were doing 10 years ago, 20 years ago?

No! It does not. The improvements in EMS come from hard hitting, get the job done paramedics and physicians who use their intelligence to build better mouse traps. Not self absorbed paper pushers sitting in some office trying to be the tough guy.

QA is not a disciplinary tool and should not be applied by bully's. If you think you need to give your team members attitude adjustments, you're in the wrong job!

As to Steve Wirth's little comment about duplication. Grown people love to work but they also hate to work doing things without purpose. Treating people like adults yields far better results than treating them like monkey's who should do as you train them to do. Creating a system in which mature, trained professionals have to feel like their efforts are a waste of time for somebody else's absurd convenience is a bad organizational plan. I doubt you'll find anything but the opposite taught in quality leadership training. 

Frank Heyman once told me that the best paramedics have some traits in common. One is that they are very difficult to manage. If you want a group of yes men, go for it. You'll be very happy and watch your mortality numbers never reach the level of the big boys in town.


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## DrParasite (May 29, 2019)

Eli said:


> The first thing taught in law school is *never *write _anything_ down unless you have to. Why do you think lawyers teach each other that only to turn around and tell everyone else to write _everything_ down?


never heard an attorney say that about law school... can you please provide a source, primarily a law school professor, who can back up that claim?





Eli said:


> To the QA people writing all that hogwash about how a vague writer will find themselves in their office and crap like that. F the HELL off. You people are nothing but losers that get your jollys by telling your buds how you ruled the day telling so-n-so off. You are the personification of what makes EMS worse today than ever before. Do you really think your petty dictator power trips does anything to improve the efficiency and performance over what we were doing 10 years ago, 20 years ago?


I think you need to calm down.  and I question if you have ever worked in EMS, because all of my former employers like things done a certain way, and if you don't want to follow their rules, there is the door.  Note: there is no exception for if you agree with those rules, it's the expectation that if you want to remain employed, you will follow the rules.  And if you don't like the rules, than work to get the rules changes, don't just not follow them.... 





NomadicMedic said:


> What’s not okay is a narrative that reads like this:
> 
> “Responded to CP. PT CAOx3. VS as charted. Treatment in flowchart. PT XFER to ED.”
> 
> Yep. I’ve gotten charts like this.


So what's wrong with that narrative?  serious question.....

If that is all that is in the PCR, than I agree.  If there is a separate box that lists OPQRST (and the appropriate answers), as well as history, meds and allergies, good.  if there is a section which lists a more detailed physical exam of the affected area, even better.  if in your flowchart, there is spare where the patient's response to all treatments is documented appropriately, as well as how they moved them during the treatment administration, I'm ecstatic.

Ok, so it might be a little light on the pertinent negatives and some basic operational stuff, but assuming a 12 lead is attached (and is normal), the vital signs are within normal limits, and there is nothing abnormal about the patient (remember, if you document by exception, than everything is normal unless documented otherwise), than I can see this being a passable (albeit barely, due to missing the aforementioned items) narrative.


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## johnrsemt (May 29, 2019)

Problem I have with the narrative from Nomadicmedic (and I know that he put it up as a problem); is what was circumstances that the patient was found in?  House extremely dusty, complaining of problems breathing?  could be due to allergies and asthma.


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## DrParasite (May 30, 2019)

johnrsemt said:


> Problem I have with the narrative from Nomadicmedic (and I know that he put it up as a problem); is what was circumstances that the patient was found in?  House extremely dusty, complaining of problems breathing?  could be due to allergies and asthma.


you know, I've never thought of it like that.  and I've never actually documented the dust level of a house....

I guess it would fall under the "document by exception," so if the house was extremely dusty, than that would be an exception to the norm, and as a result, should be mentioned as such in the narrative, especially if relevant to patient care.  if it wasn't dusty, or was the normal level of dust, than it doesn't get mentioned, because it isn't an exception.  

But it it was an asthma attack due to an allergy to dust, and it was very dusty, and the crew didn't document as such, than yes, that is a documentation failure, and should be addressed.


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## FiremanMike (May 30, 2019)

Peak said:


> You can paint a good clinical picture without duplicating your charting. Unfortunately charting has become more and more about how to get reimbursement rather than a good medico-legal record of the patient encounter. I can't tell you how much fluff is in every report that companies fax to us. We also get quite a few transports in where there were real practice issues that we need to address with medical directors, and the charting they send is completely useless and neither reflects the patients care as they gave in report nor the real reason the patient was being transported anyway. Our EMS phones are recorded and we save the recordings both for QC and legal defense, and its shocking how many EMS phone reports aren't even close to what they chart in their records.
> 
> For the record I don't have a problem with actual duplication. Some of our Docs will copy and paste RN event notes into their notes because they feel it helps them paint a better picture of the care, I think that it is redundant and unnecessary but I don't actually care. The problem is when errors arise because duplication isn't perfect. When clinicians report that the patient denies pain but then documents a subjective pain score at the same time in a flow sheet, when they document NSR in their note but their only rhythm strip or 12 lead shows a different rhythm, when they document that the patient was hypoxic even though they are in goal saturation given their medical history and didn't do anything to address their documented concern for hypoxia. I've had to ride transports where we get a fax of the run afterwards and seen all kinds of documentation of care that never actually happened or didn't reflect upon the actual patient condition.
> 
> ...



I don't care much about billing, but I do care.

With that said, the data points such as entering meds given, procedures, vitals, etc, which will generally end up duplicated in the narrative, are quite useful for data tracking, which I personally use for driving the direct of department training.

The narrative helps paint me a picture of what happened on the run, what you did, and if they got better or not.  This also helps me drive QI and future training.

Bottom line, by focusing on the billing aspect, your ignoring the desire of your training officer to make you all better.


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## FiremanMike (May 30, 2019)

Eli said:


> The first thing taught in law school is *never *write _anything_ down unless you have to. Why do you think lawyers teach each other that only to turn around and tell everyone else to write _everything_ down?
> 
> To the QA people writing all that hogwash about how a vague writer will find themselves in their office and crap like that. F the HELL off. You people are nothing but losers that get your jollys by telling your buds how you ruled the day telling so-n-so off. You are the personification of what makes EMS worse today than ever before. Do you really think your petty dictator power trips does anything to improve the efficiency and performance over what we were doing 10 years ago, 20 years ago?
> 
> ...



I use chart review as a tool to guide whether or not our folks know what the hell they're doing and to guide future training.  I'm sorry the mean QI man told you that your reports suck, but you might want to drop the chip off your shoulder and consider ANY perspective other than your own.


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## Tigger (Jun 1, 2019)

Eli said:


> To the QA people writing all that hogwash about how a vague writer will find themselves in their office and crap like that. F the HELL off. You people are nothing but losers that get your jollys by telling your buds how you ruled the day telling so-n-so off. You are the personification of what makes EMS worse today than ever before. Do you really think your petty dictator power trips does anything to improve the efficiency and performance over what we were doing 10 years ago, 20 years ago?


If you are so good at your job, why are you unable to document that very fact?


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## Eli (Jun 3, 2019)

DrParasite said:


> never heard an attorney say that about law school... can you please provide a source, primarily a law school professor, who can back up that claim?



Bryson Mills (uncle, deceased), Richard Southall, quoting his father who was also an attorney (uncle in law, deceased), Justin Morris, EMT-P --> Attorney, (initially KC,MO---> somewhere in LA the last I heard), some assistant attorney to Claire McCaskill when she was the DA for Jackson County, MO. I've never heard an attorney disagree with it. It has been a couple decades since I've had the conversation with an attorney. I did have an attorney supporting my employer 10 years ago that agreed with me when I expressed the sentiment to my employer. 



DrParasite said:


> I think you need to calm down.  and I question if you have ever worked in EMS, because all of my former employers like things done a certain way, and if you don't want to follow their rules, there is the door.  Note: there is no exception for if you agree with those rules, it's the expectation that if you want to remain employed, you will follow the rules.  And if you don't like the rules, than work to get the rules changes, don't just not follow them.... So what's wrong with that narrative?  serious question.....
> 
> If that is all that is in the PCR, than I agree.  If there is a separate box that lists OPQRST (and the appropriate answers), as well as history, meds and allergies, good.  if there is a section which lists a more detailed physical exam of the affected area, even better.  if in your flowchart, there is spare where the patient's response to all treatments is documented appropriately, as well as how they moved them during the treatment administration, I'm ecstatic.
> 
> ...


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## Eli (Jun 3, 2019)

FiremanMike said:


> I use chart review as a tool to guide whether or not our folks know what the hell they're doing and to guide future training.  I'm sorry the mean QI man told you that your reports suck, but you might want to drop the chip off your shoulder and consider ANY perspective other than your own.


The mean QI man in our minds is an idiot who wouldn't recognize a sick patient if it were in front of his face, yet tells everyone how he saved the day given the slightest chance. Unless you are one of them, you know the type. They used to say that those who can't, teach. In modern EMS, what I see is those who can't, learn to suck *** well enough to get themselves promoted into positions to get out of doing the real work of EMS.

If you feel you have to use any tools to figure out if the medics know what they are doing, you might be hiring the wrong people all the way around.  I've been in the position where my hiring criteria had to be a pulse and a certification. It is not desirable. If that situation is anything other than short term, that is the issue that needs to be addressed. Wouldn't you agree?


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## Eli (Jun 3, 2019)

Tigger said:


> If you are so good at your job, why are you unable to document that very fact?



Beauty is in the eye of the beholder. Who says that I am not able to document that fact? Is it the doc at the receiving facility? The attorney representing the agency in the face of a law suit? Some QI guy who was never anything other than average when they were in the field? As long as the professionals and the billing folks get what they need out of the chart, I don't care what some mean spirited paper pusher has to say.

Wielding subjective criteria around like a weapon is something I see happen too often in EMS. It's like a bad version of the high school popularity contest. The premise of my post was that silly comment about how if one has issues with duplication in documentation in EMS that perhaps they should find another job. The concept is asinine in my opinion and if you disagree, then your opinion is asinine as far as I am concerned. A grown person who has issues with jumping through pointless hoops is being reasonable. The person insisting that that grown person is being unreasonable is the one who is actually being unreasonable IMO. You aren't one of those people, are you?


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## Eli (Jun 3, 2019)

DrParasite said:


> you know, I've never thought of it like that.  and I've never actually documented the dust level of a house....



If it drives your decision making or would help the receiving facility focus on pertinent aspects of the patient's life, why would you not have charted it? Think of a pattern of elements like that that you've seen. Perhaps it was house tidiness. More likely it was something like ambient temperature or something like that. Did you think about including it in the narrative? My problem is that often I make a mental note of these things, tell myself to be sure to write it down and then forget. That is a product of my broadstroke outlook on life. To counteract it, I actually am more persnickety than the typical medic about keeping my clipboard with me. If I remember to write it down at the time, then I don't forget later. Otherwise.....  

Clearly you can see the value in the observation. There is some reason why it is something you've overlooked over the years. Identify it and find your workaround. Your probably not as spacey as I am, so the solution will likely be less cumbersome than mine.


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## mgr22 (Jun 3, 2019)

Eli said:


> If you feel you have to use any tools to figure out if the medics know what they are doing, you might be hiring the wrong people all the way around.  I've been in the position where my hiring criteria had to be a pulse and a certification. It is not desirable. If that situation is anything other than short term, that is the issue that needs to be addressed. Wouldn't you agree?



So how do you figure out if your medics know what they're doing?


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## FiremanMike (Jun 3, 2019)

Eli said:


> The mean QI man in our minds is an idiot who wouldn't recognize a sick patient if it were in front of his face, yet tells everyone how he saved the day given the slightest chance. Unless you are one of them, you know the type. They used to say that those who can't, teach. In modern EMS, what I see is those who can't, learn to suck *** well enough to get themselves promoted into positions to get out of doing the real work of EMS.
> 
> If you feel you have to use any tools to figure out if the medics know what they are doing, you might be hiring the wrong people all the way around.  I've been in the position where my hiring criteria had to be a pulse and a certification. It is not desirable. If that situation is anything other than short term, that is the issue that needs to be addressed. Wouldn't you agree?



Are you implying that you work for some mythical agency where everyone is at the top of their game at all times and never need to grow?

Give me a break..


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## Eli (Jun 4, 2019)

mgr22 said:


> So how do you figure out if your medics know what they're doing?




Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some *"Just Culture"* training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.

You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts _your_ performance?


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## Eli (Jun 4, 2019)

FiremanMike said:


> Are you implying that you work for some mythical agency where everyone is at the top of their game at all times and never need to grow?
> 
> Give me a break..


I am getting the idea that if you were on my team, I would love to give you a break. Maybe a very long, long break.


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## mgr22 (Jun 5, 2019)

Eli said:


> Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some *"Just Culture"* training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.
> 
> You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts _your_ performance?



I think you're raising two separate but related issues. One is collection and interpretation of information that tells you something about your employees' performance. The other is how you use and present that information.

I think it's perfectly acceptable -- even imperative -- to find a relatively objective approach for the former. In my opinion, those of us who supervise others have a responsibility to evaluate them and give them feedback based on those evaluations. The tools I use to do that might not be the same as the tools you use, due to differences in data availability, expectations, and local customs.

As for the latter issue, I don't see anyone here advocating a Theory X management style -- i.e., busting balls, as you've characterized it. I think most of us would agree that a negative bias or confrontational affect is usually counterproductive.


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## FiremanMike (Jun 5, 2019)

Eli said:


> I am getting the idea that if you were on my team, I would love to give you a break. Maybe a very long, long break.



<shrug> ok.


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## FiremanMike (Jun 5, 2019)

Eli said:


> Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some *"Just Culture"* training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.
> 
> You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts _your_ performance?



I'm going to go out on a limb and say you're at the 3-10 year mark in your career, where ego and anti-management attitude tends to overwhelm your ethos..  I'm also going to assume that you've never spent a second doing system-wide chart review.

Chart review is absolutely not the ONLY metric I use for determining competency, but it is a daily interface that I have to see where deficiencies lie.  Sometime it's a lack of mastery of the English language alone, sometimes it guides conversations that reveal significant deficiencies in clinical ability.. Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient".  These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.

It works.  I will allow that it's possible that quality improvement at your agency is lacking, but that doesn't mean it doesn't work elsewhere.  Furthermore, I think it's fair based on your abrasive attitude here that it's possible your agency does have a functional quality improvement program, but your level of arrogance blinds you to attempts to help you and/or those around you.


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## Eli (Jun 7, 2019)

FiremanMike said:


> I'm going to go out on a limb and say you're at the 3-10 year mark in your career, where ego and anti-management attitude tends to overwhelm your ethos..  I'm also going to assume that you've never spent a second doing system-wide chart review.
> 
> Chart review is absolutely not the ONLY metric I use for determining competency, but it is a daily interface that I have to see where deficiencies lie.  Sometime it's a lack of mastery of the English language alone, sometimes it guides conversations that reveal significant deficiencies in clinical ability.. Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient".  These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.
> 
> It works.  I will allow that it's possible that quality improvement at your agency is lacking, but that doesn't mean it doesn't work elsewhere.  Furthermore, I think it's fair based on your abrasive attitude here that it's possible your agency does have a functional quality improvement program, but your level of arrogance blinds you to attempts to help you and/or those around you.


Try counting decades.


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## Eli (Jun 7, 2019)

mgr22 said:


> I think you're raising two separate but related issues. One is collection and interpretation of information that tells you something about your employees' performance. The other is how you use and present that information.
> 
> I think it's perfectly acceptable -- even imperative -- to find a relatively objective approach for the former. In my opinion, those of us who supervise others have a responsibility to evaluate them and give them feedback based on those evaluations. The tools I use to do that might not be the same as the tools you use, due to differences in data availability, expectations, and local customs.
> 
> As for the latter issue, I don't see anyone here advocating a Theory X management style -- i.e., busting balls, as you've characterized it. I think most of us would agree that a negative bias or confrontational affect is usually counterproductive.




I would agree that most talk that talk. Based on my experience, I do not agree that in reality, many actually walk that walk.


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## Eli (Jun 7, 2019)

FiremanMike said:


> Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient".  These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.



Holy ****e dude! What kind of people are you hiring? I worked the hood in a system that ran 100,000 calls a year for 10+ years. We didn't have issues like those. Trauma wise our issues were with scene times. Often they were related to trying to resolve airway issues that were not going to get resolved. We didn't distinguish between Level 1 & 2 trauma centers. When to discontinue care vs not was a common source of discussion. I don't recall any reviews related to not giving meds to seizure patients. We did have one related to allowing a post ictal patient to walk to the ambulance and didn't adequately protect him before he had another seizure and was injured in a fall. That was one incident in 1990. We all learned from that one. All 88 medics. Not shocking a lethal rhythm.

All sounds to me like an employee selection issue. Perhaps the QI should start there. All in all, a management issue. Not an employee issue. You can train an unintelligent person until the cows come home. They will still be unintelligent people. I have always had good results from the Mike Taigman S.W.A.N. method. We want people on our team that are_ smart, willing to work hard, have good attitudes and are genuinely nice_. The closer to get to having all of those, the less QI you need on a routine basis.


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## FiremanMike (Jun 7, 2019)

Eli said:


> Holy ****e dude! What kind of people are you hiring? I worked the hood in a system that ran 100,000 calls a year for 10+ years. We didn't have issues like those.



Lol, ok bro.. go on and believe that.


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