Narrative vs entire PCR

DrParasite

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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.
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
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:
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.
 

Tigger

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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.
 

DesertMedic66

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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?
 

luke_31

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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.
 

DesertMedic66

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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.
 

RocketMedic

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

Remi

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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.
 

Akulahawk

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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.
 

Joe Kenney

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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
 

CWATT

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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

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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.
 

Eli

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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.
 

DrParasite

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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?
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....
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.
 

johnrsemt

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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.
 

DrParasite

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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.
 

FiremanMike

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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.
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.
 

FiremanMike

EMS Coordinator
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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.
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.
 

Tigger

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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?
 

Eli

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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.

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.
It has been awhile since I slammed out that little soapbox tirade. Not sure what you are referencing but I believe I was criticizing that quote about duplication. I agree, pertinent data must be in the chart. But if it is in the drop down box area, don't smack some medic's pecker because he didn't include it in the narrative as well.



I have zero formal training in legal matters. My opinion along with a buck can get me a soda at McDonald's.

But...

What I do have is substantial experience in EMS organizations, including taking a couple large EMS out of the gutter and making them top notch. There have 5 times when there were legal cases in which I was a significant part of, 4 criminal as a witness & 1 civil as a defendant. In the criminal cases, from my perspective the opposing counsel did not score a single point in discrediting my work or my testimony. One DA described me as a fantastic witness and another as "couldn't have asked for a better medic to have run the call". In the civil case, when my report was criticized by my boss as weak the attorney hired by the county countered with telling her that it was great... not too much, not too little. That case never went past summary judgement. (It was a bogus suit to start with.) But my actions and my report ensured that the country didn't even have to settle the case. I don't want to toot my horn too much. From a legal perspective, none of the cases were that challenging. The criminals cases were formalities where everyone knew who killed who. There was no wondering if it was Col. Mustard or someone else. The civil case was just a case of an ambulance chaser trying to squeeze some money out of my employer. I am not the type of paramedic or manager that your dress up and take to prom. I am the type that you hire when you want things done well.

Something in that original post pushed my button. I think it was the bit about duplication and find another job. I took the time to email it to myself and later showed the comment to a few buddy's. Not a single person agreed with the statement. The group included street medics, former QA bosses and a former CEO of an EMS company. I have NEVER heard anyone utter such a idiotic sentiment about the ridiculous duplication we have to do these days.

Cheers
 

Eli

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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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