10.3 Documentation and Communication

The PCR Is a Legal Record

The patient care report (PCR), sometimes called the run report, is the permanent record of what you found, what you did, and how the patient responded. It supports continuity of care when you hand off to EMS or the hospital, it feeds quality review, and it is a legal document that can be read in court years later. The governing principle the exam loves is blunt: "if it wasn't documented, it wasn't done." An intervention you performed but never charted is, legally, an intervention you cannot prove you performed.

A complete EMR record generally captures:

• Times — dispatch, on-scene, patient contact, interventions, and transfer of care.
• Assessment findings — primary and secondary assessment, vital signs with the time taken.
• Interventions — every action (oxygen, bleeding control, airway, CPR/AED, medication assistance) and the patient's response.
• Reassessment — repeated vitals and changes over time.
• Disposition — who took over care and where the patient went.

Missing times, missing reassessment, or a missing handoff name are the gaps the exam will punish.

Objective vs. Subjective, and the Do/Don't List

Good charting separates what you observed and measured (objective) from what the patient or bystanders told you (subjective). "Patient states the pain is 8 out of 10" is subjective; "radial pulse 110, skin pale and diaphoretic" is objective. Write the patient's own words in quotes when relevant. Never substitute your conclusion for the data — record the findings, not a diagnosis you are not authorized to make.

The most defensible documentation phrase is the specific, objective one. "BP 88/50, skin cool and clammy, patient confused" beats "patient looked shocky," because the first records measurable facts a reviewer can interpret independently.

Correcting Errors and Reporting Special Situations

Everyone makes charting mistakes; what matters is the correction method. The legal standard is to draw a single line through the error, initial and date it, and write the correct information nearby. You do not erase, white-out, scribble until illegible, or backdate — those actions look like concealment and destroy the record's credibility. Late additions are added as a clearly dated addendum, not squeezed in to look original.

Several situations carry extra documentation weight:

• Medication assistance (e.g., helping with an epinephrine auto-injector, naloxone, aspirin, or oral glucose per protocol): record the medication, dose, route, time, who administered it, and the patient response.
• Refusals of care: document that the patient is a competent adult, that risks were explained, and exactly what was refused — refusals are high-liability events.
• Transfers and handoffs: record the name/level of the receiving provider and the time.
• Unusual incidents: crimes, exposures, and equipment failures get factual, neutral documentation.

Verbal and radio communication mirror these values: concise, organized, and factual. A clean handoff report typically gives the unit and the patient's age and sex, the chief complaint, a brief relevant history, current vital signs, and the care provided — enough for the next provider to take over without confusion. On the National Registry, cognitive exam results generally post within about two business days once all requirements are met, but field documentation rules always come from your local system and medical direction.

Radio, Dispatch, and Therapeutic Communication

Communication on a call moves through several channels, and the exam expects discipline on each. With dispatch and the radio, use plain language (not personal codes), press the transmit button, wait a moment before speaking, keep the message brief, and use echo/closed-loop confirmation so orders from medical direction are read back and verified. Never broadcast a patient's name over the radio; protect confidentiality even on the air.

A structured radio report to the receiving facility or incoming unit usually follows this order: identifying unit, patient age/sex, chief complaint and mechanism, brief pertinent history, level of consciousness, vital signs, care provided and response, and estimated time of arrival.

Therapeutic communication is how you talk to the patient and is tested in scenario form. Adapt to the patient — face a hearing-impaired patient so they can read your lips, use a calm tone with an anxious patient, and respect cultural and personal space. Honesty matters: explain what you are about to do before you do it.

These habits are not soft skills; they improve the accuracy of the history you collect, increase cooperation and consent, and reduce the conflict that leads to refusals and complaints — all of which feed directly back into the quality of your documentation.

The written narrative usually follows a recognized format so any reviewer can follow the story. Common structures are CHART (Chief complaint, History, Assessment, Rx/treatment, Transport) and SOAP (Subjective, Objective, Assessment, Plan), which keep subjective and objective data clearly separated. Whatever the format, the record is protected health information: under HIPAA, the PCR may be shared only for treatment, payment, or operations. Write legibly, use only system-approved abbreviations, and never leave blanks that suggest a step was skipped.