Documentation

Narrative Format, Strengths and Weaknesses

Strengths

Noted strengths of the narrative documentation format include the following:

  • Is a simplified method
  • Allows the author to control what is said
  • Promotes chronological documentation—easy to document and track timing of events if documentation is done correctly
  • Works in all clinical environments
  • Is easy to teach or learn
  • Requires no special form—other than blank paper
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    Weaknesses

    Noted weaknesses of the narrative documentation format include the following:

    • The author is given no guidance about what to say.
    • The author must learn through experience, decide what is important to document, and develop his or her own system for organizing a note.
    • This freeform can produce notes that could be any of the following:
    1. Fragmented
    2. Disjointed
    3. Noninformative
    4. Rambling and subjective
    5. Inconsistent with what is documented from one author to the next
    6. Too wordy—making it difficult to pick out patient trends and problems
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          This format requires a lot of time to personalize data for each patient.It’s difficult to retrieve information, since everything must be read to find a certain fact.
        1. It's difficult to retrieve information, since everything must be read to find a certain fact.
        2. The patient outcomes may not be consistently documented, so it becomes hard to track progress or identify lack of progress.

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