The fire extinguisher is not just for show
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.My statement was, the narrative is the most important part of your patient care report. Full stop.
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.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.
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
See what I mean?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.
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:
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.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.