Which statement is NOT appropriate to document in the narrative section of a PCR?

Which statement is NOT appropriate to document in the narrative section of a PCR?

• A. The patient’s initial assessment findings
• B. The general impression
• C. General impression revealed that the patient was intoxicated.
• D. The patient’s treatment provided and response

Answer: (C)

In the narrative, you should record what you directly observed and what you did, in clear, objective terms. The general impression field is where you note your overall assessment in a concise, interpretive sense, but it should not be the basis of a single narrative sentence that declares a diagnosis. Saying that the general impression revealed the patient was intoxicated is not appropriate for the narrative because it moves from observable signs to a diagnostic conclusion rather than listing concrete, objective data. A proper narrative entry focuses on specific, observable findings and actions. For example, you would describe signs you could verify—such as slurred speech, unsteady gait, odor of alcohol, and the patient’s own report of recent drinking—and then document the treatment you provided and the patient’s response. If there’s a separate field for the general impression, you summarize your overall impression there, rather than embedding it as a narrative sentence. This keeps the narrative factual and verifiable, avoids premature conclusions, and aligns with how PCRs are reviewed.

In the narrative, you should record what you directly observed and what you did, in clear, objective terms. The general impression field is where you note your overall assessment in a concise, interpretive sense, but it should not be the basis of a single narrative sentence that declares a diagnosis. Saying that the general impression revealed the patient was intoxicated is not appropriate for the narrative because it moves from observable signs to a diagnostic conclusion rather than listing concrete, objective data.

A proper narrative entry focuses on specific, observable findings and actions. For example, you would describe signs you could verify—such as slurred speech, unsteady gait, odor of alcohol, and the patient’s own report of recent drinking—and then document the treatment you provided and the patient’s response. If there’s a separate field for the general impression, you summarize your overall impression there, rather than embedding it as a narrative sentence. This keeps the narrative factual and verifiable, avoids premature conclusions, and aligns with how PCRs are reviewed.