How to Write a Patient Care Report

Keep a notebook near to record everything you do on every call.

Keep a notebook near to record everything you do on every call.

A patient care report, more commonly known as a PCR, is a summary of what went on during an emergency call. EMS and other first-responders use the PCR to fill in the details of every call -- even the ones that get canceled or deemed false alarms Every department has its own procedures for filing a PCR and many companies now use EPCRs, or electronic patient care reports, but there are many details common to most patient care reports.

Document Details

The PCR usually begins with the time the call came in and under what circumstances. The operator who took the call provides you with the address and complaint that’s called in. The operator also notes the time of the call and when she sent out the message. You’ll note every detail you received before you met the patient, including how long it took you to arrive on the scene from the time you took the call. Every piece of information in a PCR is vital because it may have to be used in court.

Tell a Story

The next part of the PCR is called the narrative and should include notes you took about what you saw when you arrived on the scene and how you interpreted the situation. Write down the chief complaint of the caller based on what she tells you. Feel free to use shorthand if it’s part of your group’s standard operating procedures, or SOPs. For example, you might write “arrived on scene to find 22 yo female lying on the floor and 23 yo male standing over her. Female was bleeding from back of head, while male was holding a broken bottle.” Include statements people make to you and put them in quotation marks.

Assessment

Now your training kicks in and you need to decide what to do. You may have to act quickly to provide immediate medical care, but remember what you were thinking at the time, because later, when you write your PCR, you’ll have to relate those findings. Use medical terms such as “male was staggering and smelled strongly of alcohol,” instead of “guy was drunk.” Keep notes about any history you gather about the patient too that you’ll include in the report, such as allergies, HIV status or if patient is pregnant.

Treatment

Finally, end the PCR by accounting for everything you did to help the patient. Record vital signs and whatever steps you took to neutralize bleeding, etc. Write down what medications you gave the patient as well as what other medical treatments you performed. The more details you can include the better. Include information about how the patient responded to any treatments you performed and then write about putting the patient in your rig and transporting her to the hospital. Conclude with the time you turned her over to the emergency room and what condition she was in at the time.

 

About the Author

Linda Ray is an award-winning journalist with more than 20 years reporting experience. She's covered business for newspapers and magazines, including the "Greenville News," "Success Magazine" and "American City Business Journals." Ray holds a journalism degree and teaches writing, career development and an FDIC course called "Money Smart."

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