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9 top patient care report tips for EMTs and paramedics

Article updated August 10, 2018

When you write a patient care report, pretend that it will someday be enlarged and projected onto a giant screen for a court of law and general public to scrutinize. These questions should pop into mind:

  • How is your spelling?
  • How well are your thoughts organized?
  • What do these things say about you?
  • How did you add to or change an automated narrative?
  • How do they affect patient care?

There are simple concepts and tips to keep in mind whenever you write a PCR:

  1. Make sure that your spelling is correct. When in doubt, look it up or change the word.
  2. Use only approved and recognizable medical abbreviations.
  3. Double-check the patient’s name, date of birth and other identifying information to ensure accuracy. If you are unsure, document the reason(s).
  4. Double-check each checklist box to make sure that everything is covered. There’s nothing quite like noting that a glass eye is midrange and reactive to light. I have seen it done.
  5. Employ a consistent method for tracking time and document travel times, treatment times and changes in a patient’s condition.
  6. Be sure to describe what you see and hear (and smell, if necessary) throughout the call.
  7. Identify and attribute statements made by others, especially statements about what happened prior to your arrival.
  8. Be an artist and paint a picture! Organize a detailed sequential narrative of the call from inception to emergency room.

If you are using a hand-written patient care report or hand-off form make sure to print clearly in black ink (unless your agency requires blue). columnist David Givot, a seasoned EMS employee with three years of law school under his belt, is looking to the future of EMS. He has created as a first step toward improving the state of EMS through information and education designed to protect EMS professionals nationwide.