Narrative vs entire PCR

[lacey15890]

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

 

[DesertMedic66]

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.

 

[Peak]

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.

 

[NomadicMedic]

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”.

 

[Flying]

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.

 

[NomadicMedic]

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.

 

[Peak]

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.

 

[DrParasite]

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.

 

[Qulevrius]

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.

 

[NomadicMedic]

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.

 

[Carlos Danger]

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.

 

[NomadicMedic]

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?

 

[PotatoMedic]

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.

 

[Carlos Danger]

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.

 

[Tigger]

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”.

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.

 

[DrParasite]

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.......

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.

 

[Tigger]

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.

 

[NomadicMedic]

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.

 

[Carlos Danger]

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.

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.

 

[NomadicMedic]

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?