Chapter 4: Patient Care Report (PCR) Composition Notes

Steps to Creating a Narrative

Set the scene

• Add the method of arrival to the location if unique/unusual

  1. To explain the delay in patient contact and care
  • Describe the status of the location/surroundings of the patient
  • Mention other first responders (police, fire) that are present
  • Mention family members that are present at the scene
  • What position the patient was found in
  1. Prone, supine, left/right lateral, Fowler’s, Trendelenburg
  • Mention patient care performed by first responders before arrival

Create an index of suspicion

• Presentation of patient

  • Physical assessment
  • History of medical conditions
  • Medication history and list
  • Findings
  • Pertinent negatives
  1. Mention partial vitals to ensure that a conscious choice is obvious
  2. Things/factors/conditions that are significant in their absence
  3. Ex: dispatched for an asthma attack with no pertinent symptoms
  • Must always have evidence beyond a reasonable doubt to support theories and treatment, important in case of future medical and legal issues.

Note performed interventions

• Treatment provided to the patient
  • Ex: non-rebreather mask, nasal cannula, epinephrine, aspirin, Narcan

Note patient responses/changes

• Changes that occur because of or independent of interventions
  • Ex: how a patient responds when put on oxygen → impact on their O2 saturation

Note the movement of the patient

• Record how packaging or transport of patient was conducted

  • Mention how the patient was prepared to be transported
  • Mention any lifting and moving devices used
  1. Ex: the process of the transfer of the patient from an armchair to a stair chair to a stretcher to the ambulance

Note the monitoring of the patient

• Checking the patient’s vitals throughout the transport
  • Every 5 minutes if the patient is not stable
  • Every 15 minutes if the patient is stable
  • Must provide timestamps for all vital signs taken
  • Mention if ALS (paramedics) is canceled if not needed

Detail transfer of care

• Formally transfer care of the patient to the hospital system
  • Give verbal report to the person who has authority to take responsibility for the patient, must be a person with adequate authority and medical credentials
  • At WEFAS, the person must provide their name and initial a transfer form
  • Mention any delays such as mechanical issues or wait times that affected the transfer of care

Notes

• At WEFAS, an EMT must enter patient information and create a chart before the end of a shift or departure.
  • Always mention errors made to protect oneself from future legal issues.
  • Charts are still created for patients who refuse medical attention (RMA).