One of the most difficult things about EMS documentation is the narrative of the patient care report or PCR. The general idea it to tell the story about what happened, how it happened and what you did about it. Below are some of the general categories to consider when writing your narrative.
Standard Precautions
What standard precautions did you use and why?
Scene Safety
Was the scene safe when you arrived? Did you have to make the scene safe? What did you do and why did you do it? Did this cause a delay in patient care? If so, how long?
Mechanism of Action/Nature of Illness
What was the MOI or NOI?
Number of Patients
If you had more than one patient at the scene, record which patient it is and out of how many. "Patient 2 of 3."
Additional Help
If additional help was needed, what kind did you need? When did you call for the extra help and what time did they arrived? Was there any delay in patient care due to this?
Cervical Spine
What cervical spine precautions were taken and why?
Initial General Impression
How did the patient appear when you first arrived on scene?
Level of Consciousness
Be sure to record what the patient's LOC was upon arrival and any changes. The time the change took place should also be recorded. Also, note if no changes occurred.
Chief Complaint
Record and quote any complaints by the patient. This also includes pertinent negatives like a patient who has chest pain but no numbness or tingling.
Life Threats
List all interventions and how the patient responded to them.
ABCs
Document everything you find and any interventions performed. This includes noting that breathing was adequate or pulse normal. Don't just put the things that are wrong with the ABCs.
Oxygen
Was oxygen given? What delivery method was used and how much?
Primary, Secondary, Patient History, or Reassessment
Write the type of assessment done and all findings.
SAMPLE/OPQRSTI
Record all relevant answers.
Vital Signs
Record the times and findings, depending on if your service requires them to be in the narrative as well.
Medical Direction
Quote any orders given to you by medical control and who gave them.
Management of Secondary Injuries/Treat for Shock
Record all interventions, the time, and response by the patient.
Everything you need to be successful on the NREMT and in your EMS career.
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