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Sexual Assault

Narrative Documentation: Is There One Right Way?

{Once again, let me preface this by saying I am not the definitive authority on this topic. I am one woman with an opinion who provides care to adult and adolescent domestic violence and sexual assault patients. At the end of the day, you need to decide the best course of action to take for your practice and patient population. Hopefully, this spurs some discussion, where needed, as that is its intent.}

So I was asked by an FHO reader if I would comment on the best way to document the narrative portion of the history. That is, the history of the patient’s chief complaint. Always up for stepping into the abyss, I said, sure–why not? After all, it comes up in pretty much every single testimony workshop I teach.

Perhaps the best way to begin this discussion is by saying, I don’t necessarily believe there is one right way to document the narrative history of the assault. Some of you out there write down everything the patient says, verbatim. I think that’s weird, but I don’t necessarily think it’s wrong.

Why do I think it’s weird? Because I personally can’t listen to a patient and also transcribe everything the patient says. When I do that, I miss all the rich, non-verbal communication that happens, and that impacts patient care. But that’s just me. Also, most people aren’t terribly accurate at capturing every single word the patient says, which I imagine defeats the purpose of choosing that method in the first place. So for me, it feels like a missed opportunity to connect with a patient as a person (and not a crime scene or a complainant), and begin the process of assessing their well-being.

My preference is to summarize, except where my summary couldn’t possibly do justice to the patient’s account of events or state of mind (threats, fear, etc.). Then I add quotes. This gets me where I need to be to take care of this patient in the most comprehensive way possible. And since the purpose of obtaining the narrative history of the assault is to guide my exam process, focus any sample collection the patient may desire, and inform the patient-specific discharge and follow-up plan, I don’t feel like I could more effectively accomplish any of that if I wrote down what the patient said verbatim.

I do think there are some wrong ways to approach narrative documentation, though (and I see them all in my travels):

  1. Having the patient write it out for you (and even worse, having them sign it). This is not medical documentation. And doing this says that the end goal is litigation rather than good quality patient care. If you want to tell me it’s to avoid inconsistencies between what the patient reported to law enforcement and what the patient tells us, I’m going to call BS on that right now–1.) not all of our patients even engage with law enforcement, and some will do so long after the exam; and 2.) I challenge people under duress to write down details of a traumatic event and then several hours later, in a different environment with different people looking over your shoulder, do it again–now see how many inconsistencies are there.
  2. Obtaining the narrative history of the assault from law enforcement rather than the patient. Except in extraordinary circumstances (e.g. patient is brought in unresponsive and you take a report from the police) I can’t come up with a justification for this approach.There are reasons patients tell healthcare providers different details than they tell law enforcement–they may feel more comfortable with us; they may believe there’s a different purpose for providing the info (and there is); we don’t have a gun on our hip at the time we’re caring for them. Also, how many times have you gone into a patient’s room to get a history, and then had them provide totally different information when another physician or nursing colleague went in to see them? Exactly. People are not machines. Different questions elicit different responses, even when focused on the same event. Inconsistencies are both expected and explainable.
  3. Never having it (and the rest of the medical-forensic documentation) peer-reviewed. Some sort of quality assurance/quality improvement process is a must. How do you know you are providing comprehensive, appropriate care and hitting identifiable benchmarks for quality if your work is never reviewed?

So if I was going to summarize, I’d say this: if you have a clinical rationale for documenting in your particular style, you’re probably just fine (assuming your work is also being peer-reviewed). If your approach to documentation of the narrative history is dictated by any non-clinician professionals (e.g. law enforcement or prosecutors like you to document in a certain way), or you see its purpose as being primarily for the investigation and prosecution of the reported crime, I¬†think that’s problematic. And if your approach simply doesn’t resemble healthcare at all, well, it may be time to reassess.

8 replies on “Narrative Documentation: Is There One Right Way?”

Interesting discussion. In my state we have a wide range of practice. I wonder if there is any research about this.

To my knowledge there really isn’t–and it would be interesting to see what was being measured (medical vs legal issues) if there was.

When I am teaching history taking or performing peer review, I tend to focus on the importance of the medical exception to hearsay, and not just as a SANE, but as a nurse because you never know when your going to be ask to give a deposition or provide testimony. That saying we all learned in nursing school “If you didn’t document it, it didn’t happen” is always in the back of my mind. Can you please comment (in your opinion of course) how this is affected when we “summarize” a patient’s statement? It is my understanding of this exception that we should be quoting the patient as much as possible. I agree with you that full and complete sentences fully take away from our role as health care professionals, but I usually look for fragmented sentences in quotes that utilize the patient’s language and convey the details that were provided to me in their own words. Is there any case law regarding “summary” vs “direct quotes”?

Jaclyn,

When I am peer reviewing a record or evaluating testimony, I am personally looking for this: was that clinician performing optimally in their role as a clinician? Did this patient get comprehensive care during this encounter, and was that care better than what they would have received had they rolled into any random ED in the country and been seen by the staff there versus by forensic specialists? Too often the answer is no–patients with medication allergies get the wrong meds or get no meds without a plan for follow-up; patients aren’t assessed for HIV, Hep., suicidality, etc.; obvious healthcare issues apparent in the record are ignored or missed. I could go on and on. So I guess my general feeling is, when the focus is on getting every word down in the narrative history of the assault, it is often at the expense of other things. However, if that’s your process, go for it–just be able to articulate why you do it that way. And make sure other things don’t end up going by the wayside because the focus is on verbatim documentation. But no one should espouse that verbatim documentation is the way it has to be done.

In terms of case law, I don’t think it matters. The case law we highlight when teaching on testimony is about testifying to hearsay statements or being qualified as an expert. Neither of those requires wall-to-wall verbatim statements in the medical record. Keep in mind, though–I’m not a lawyer and this is not legal advice, so take it for what it’s worth. But again–I don’t think it matters. This doesn’t really come up in other areas of healthcare, even areas with high probability of seeing the inside of a court (such as in med mal cases). The issue is that documentation is thorough, accurate and complete. That holds true here, as well.

I feel like there’s some level of paradox in me saying this, but here it goes: don’t sweat the court stuff. Be a really terrific (current, competent, comprehensive) clinician, because my experience is that’s the most important thing there is–both for patient outcomes and potential legal ones. I know I spend a lot of time discussing and teaching issues related to testimony, but one constant theme in everything I teach is the importance of being a great healthcare-focused clinician. If you can be that, the lawyers, whose job it is to get hearsay statements in if they want them, will have an easier time of it. But if there’s any question about the best way to document, I always encourage people to discuss the issue with hospital risk management professionals, and medical directors–two groups whose input on these types of issues can be exceedingly valuable.

Hope this makes sense. Thanks for reading, as always.

Appreciate the further clarification. May I quote your last paragraph (with attribution, of course) should we do an in-service on documentation?

Ma’am, you are a wealth of information and several of our Texas SANEs utilize your site for guidance. A questions that comes up time and again, when documenting a patient history, is should we destroy/shred the original “scrap” page that was utilized when taking the chief complaint or include it in the record?
In the past (10-15 years ago) we kept everything and submitted it all. The reason we started transcribing the scrap note to the original documentation was that the handwriting often was terrible and several arrows or side notes written that appeared messy and difficult to navigate.
We want the record to legible. In my opinion, anywhere else in medicine we do not keep every little scrap note with vitals, a weight, medication or phone number written on them and scan it into the record. We would be ripping of the paper on the stretcher if that was the case or cutting a piece of our surgical scrubs to include in the medical record because we jotted something down that typically would be added immediately to the patient record or electronic file.
What are your thoughts and is there a written law that states every piece of paper, sticky note, stretcher paper should be considered evidence because it is a medical forensic exam?
Thank you for your valued opinion!

Sheilah,

My opinion (and it is simply that, so if there’s a question, check with your hospital legal–not your prosecutors, but your hospital counsel who would address risk management issues) is that we do not need to keep every scrap of paper. We need to make sure we meticulously transcribe the information and then I am comfortable shredding it. That was my practice when I exclusively saw forensic patients, and continues to be when seeing primary care patients, since I find it impersonal to type on a computer while they talk with me. I agree, it’s no different than if you are running around the ED grabbing vitals off of a patient, and you write them on a paper towel (or even your hand) and then transfer the info into the medical record. We don’t keep the paper towel (or photograph our hand).

When you testify in court you have to testify that this is the documentation that was completed contemporaneously to the exam. That it accurately reflects the encounter and was completed consistent with agency guidelines and best practices. If you can explain why the information wasn’t placed immediately in the record that should be sufficient…if the issue even comes up, which in my 22 years of doing this work, it hasn’t.

Thanks for reading!

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