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.