Narratives That Stand Up to Audits: 4 Documentation Essentials

How many times have you read some version of this EMS narrative?

“Arrived on scene to find the patient sitting on the couch in no distress. Pt cc not feeling well since this morning. Patient assessed and all vitals WNL. Patient assisted to the stretcher and loaded on to the ambulance. Patient transported without incident. Care transferred to RN at receiving facility ER.” End of report.

There’s nothing wrong with it, but it is a problem. It’s so vague and generic it could apply to almost any transport. Sometimes narratives like this are written about a patient who has a minor illness and, at most, needed an appointment with their doctor. But sometimes they’re written about a patient who’s septic and requires immediate, life-saving care when they get to the hospital.

The problem is if most, or even some, of your agency’s documentation looks like this, your billing company, oversight authorities, auditors, and lawyers have no way to tell the difference. You’re likely leaving money on the table or at risk of having to pay the reimbursement you do receive back if you’re audited. And you’re exposing your agency to significant legal and compliance risk.

It’s common for crews to think they don’t need to say much in the narrative due to filling in the data fields on the ePCR. But the reality is the narrative should be the highlight of EMS documentation. It’s where other healthcare providers, auditors, and lawyers look first. And a high-quality, thorough narrative is the best way to ensure accurate, compliant billing.

Every transport is unique so there is no one-size-fits-all formula for narratives, even if you follow a system like CHART or SOAP. And you don’t need to, and shouldn’t, repeat every data field in the narrative.

But there are four things to always consider when drafting a narrative.

1. History of the Present Illness

Not the patient’s entire medical history, but the history relevant to the current transport. This should include either the mechanism of injury or the onset or change in symptoms. This is often missing from narratives but is critical for determining appropriate billing.

2. Assessment of the Patient

Include what exactly was assessed and the findings. Such as the patient’s presentation including if anything was different than normal, external factors impacting the patient’s condition, and relevant symptoms and pertinent negatives. If the patient is complaining of pain, a pain scale and a description of the pain should be documented. And if the patient is injured, the injury should be described.

3. Explanations

If medications were given or interventions were performed, they should be explained. Conversely if an intervention was withheld or abnormal vitals were not addressed that should also be explained. Don’t expect readers to make assumptions or connect the dots themselves, all clinical decisions should be explained in the narrative.

4. Make it a Story

Think of what you would say if you were telling someone the story of the transport. If you’d include a detail or piece of information, it should go in the narrative. If you’d leave it out because it wasn’t relevant to the particular transport, even if it’s something you always do, you can probably skip it in the narrative. And don’t make the reader track down crucial pieces of information by referring them to other parts of the report, i.e. “see tabs” or “as above”.

Narratives shouldn’t be so routine that each one sounds the same. And they definitely shouldn’t be treated as an afterthought. Emphasizing the importance of detailed, specific narratives for each transport will improve your reimbursement, reduce your compliance risk, and help shield your agency from overpayment demands and penalties in the future.

For more insights on how to optimize your compliance documentation, join us for our next webinar:

📣 EMS Billing Compliance: Preventing Costly Documentation Mistakes
📆 Tuesday, June 23rd at 1:00 PM EST
👉 Register Here