The Importance of EMS Documentation
The patient care report (PCR) is a legal document that records your assessment findings, interventions, and patient outcomes. The NREMT tests documentation principles because poor documentation can result in legal liability, continuity of care failures, and billing issues. The standard in EMS documentation is: if you did not document it, you did not do it.
Documentation Formats
CHART Method
- C - Chief Complaint: The patient's primary reason for calling EMS, in their own words when possible
- H - History: OPQRST and SAMPLE history findings
- A - Assessment: Physical exam findings, vital signs, diagnostic results
- R - Treatment (Rx): All interventions performed and patient responses
- T - Transport: Destination, mode (emergent vs. non-emergent), changes during transport
SOAP Method
- S - Subjective: What the patient and bystanders tell you (symptoms, history, complaints)
- O - Objective: What you observe and measure (vital signs, physical exam findings, interventions)
- A - Assessment: Your clinical impression or field diagnosis
- P - Plan: Treatment provided and transport decision
Essential Documentation Elements
Every PCR should include:
- Date, time, and location of the call
- Patient demographics (name, age, sex)
- Chief complaint and history of present illness
- SAMPLE history
- Physical exam findings (be specific and objective)
- At least two sets of vital signs with times
- All interventions performed with times and patient responses
- Changes in patient condition during transport
- Hospital handoff information
Documentation Best Practices
Be objective: Document what you observed, not your opinions. Write "patient states she drank a fifth of vodka" not "patient is an alcoholic." Write "breath smells of alcohol" not "patient is drunk."
Be specific: Write "3 cm laceration to the right forearm" not "cut on arm." Include measurements, locations, and descriptions.
Document refusals thoroughly: If a patient refuses care or transport, document that you explained the risks, that the patient understood, and that the patient was competent to make that decision. Have the patient sign a refusal form and document witnesses.
Corrections: If you make an error, draw a single line through the incorrect entry, write "error" above it, initial, and date. Never erase, use correction fluid, or obliterate entries.
Legal Considerations
The PCR is a legal document that may be used in court. Documentation should be accurate, complete, and timely. Late entries should be clearly marked as such with the time and date they were actually written. Never alter a PCR after a legal claim has been filed. Document pertinent negatives (relevant findings that are absent) as well as positive findings.