5.2 Documentation & Communication

Patient Care Report (PCR)

The Patient Care Report (also called the prehospital care report or run report) is the official written record of the EMS call. It is a legal document and serves multiple purposes:

• Continuity of care -- Communicates patient information to the receiving facility
• Legal record -- Protects both the patient and the provider in legal proceedings
• Quality improvement -- Used for system-wide data analysis and performance review
• Billing and reimbursement -- Required for insurance and Medicare/Medicaid claims
• Research and education -- Contributes to EMS data and training materials

Essential PCR Components

Minimum Data Set

The minimum data set is the baseline information that must be collected on every patient encounter:

Patient Data:

• Chief complaint
• Level of consciousness (AVPU)
• Systolic blood pressure (patients >3 years old)
• Skin perfusion (capillary refill for patients <6 years)
• Skin color and temperature
• Pulse rate
• Respiratory rate and effort

Administrative Data:

• Date and time of the incident
• Time of dispatch, en route, on scene, transport, and arrival
• Unit and crew identification
• Patient disposition

Documentation Best Practices

• Document objectively -- record what you see, hear, and measure
• Use quotes for patient statements: Patient states, "My chest hurts"
• Avoid subjective terms like "appears intoxicated" -- instead describe observed signs
• Document refusals thoroughly with competency assessment and risks explained
• If an error is made on a paper form, draw a single line through it, initial, and write the correction
• Never alter or falsify a PCR -- this is a legal and ethical violation
• Late entries should be clearly labeled with the date and time they were added

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Radio Communication

General Principles

• Press the button, wait 1 second, then speak (avoids clipping the first word)
• Speak clearly and at a moderate pace
• Keep transmissions brief -- the radio channel is shared
• Use plain English unless local protocol specifies codes
• Do not transmit patient names over the radio (HIPAA)
• Confirm receipt of orders by repeating them back

Hospital Notification Format (SBAR)

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Transfer of Care

Transfer of care occurs when you hand off patient responsibility to the receiving facility or provider:

• Provide a face-to-face verbal report to the receiving nurse or physician
• Include all pertinent findings, treatments, and changes during transport
• Ensure the receiving provider acknowledges the handoff
• Never transfer care to someone with a lower certification level
• Leave a copy of the PCR with the receiving facility
• Transfer of care is not complete until the receiving provider accepts responsibility

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HIPAA Considerations

HIPAA (Health Insurance Portability and Accountability Act) governs the privacy and security of patient health information:

• Protected Health Information (PHI) includes any information that can identify a patient: name, date of birth, address, Social Security number, medical records
• PHI may be shared for treatment, payment, and healthcare operations without specific patient consent
• Do NOT discuss patient information with people who do not have a need to know
• Do NOT post patient information or images on social media
• Radio transmissions should avoid using patient names
• Report any suspected HIPAA breaches immediately

Why Documentation Matters Legally

In court, the rule of thumb is blunt: "If it wasn't documented, it wasn't done." The patient care report is frequently the only objective record of an encounter that may be litigated years later, long after the crew has forgotten the call. Thorough, objective, contemporaneous documentation is the EMT's best protection and the patient's best guarantee of continuity. Conversely, falsifying or altering a record - even with good intentions, such as "correcting" a missed vital sign after the fact without labeling it a late entry - is fraud that can end a career and expose the provider to criminal liability.

Narrative Writing Methods

A strong narrative tells the story of the call in a logical, reproducible order. Common structured formats include:

Whatever the format, document objectively - record measurable findings ("patient ambulated 10 feet with a steady gait, answered orientation questions correctly") rather than conclusions ("patient appeared drunk"). Put the patient's own words in quotation marks, and avoid words you cannot defend.

Refusals: The Highest-Risk Documentation

A patient who refuses care generates the most legally dangerous report an EMT writes, because a bad outcome after a refusal is a classic source of lawsuits. A defensible refusal documents that the patient was alert, oriented, and competent, that the risks of refusal (including serious injury or death) were explained in plain language, that the patient demonstrated understanding, that alternatives and the option to call 911 again were offered, and that a refusal form was signed (ideally witnessed). Never document a refusal as a single checkbox.

Special Reporting Situations

Some events trigger additional, legally required reports beyond the routine PCR: suspected child or elder abuse, certain injuries (gunshot and stab wounds), specific communicable diseases, and exposure incidents to the crew. Knowing which situations require mandatory reporting - and documenting them factually without accusation - is part of competent EMS communication.