How to write a Patient Care Report (PCR) narrative for EMS

Learn how to write a patient care report that meets industry standards. Craft an effective PCR narrative with this helpful checklist and examples.

An EMS Patient Care Report (PCR) must encompass several vital components to meet the standards for reimbursement. A detailed PCR narrative stands as one of the primary criteria stipulated by the Centers for Medicare and Medicaid Services (CMS), which establishes industry standards.

Observe this checklist, along with suggestions and examples, to craft the most effective narrative for your PCR.

Essential elements

The PCR narrative should comprehensively outline the patient’s condition, medical interventions, medications administered, and services provided. At the very least, it should encompass the patient’s assessment and any responses to treatment administered en route.

Here are some questions to address when composing a PCR narrative:

• What was the nature or type of dispatch?
• What was the initial scene assessment upon arrival? What was the patient’s condition and activity? In what position was the patient? What was the patient’s ambulatory status?
• How did you transfer the patient to the ambulance?
• Which medications were administered, and at what dosages?
• What supplies were utilized during the call?
• Were there any safety concerns? Describe them.
• Was an existing IV monitored? Was it locked or flowing?
• Was trauma the suspected cause of injuries? If so, detail the traumatic event.
• Other relevant observations at the scene (e.g., presence of additional EMS responders or law enforcement).

Suggestions to write a narrative

The PCR is the foundational document supporting the medical necessity for ambulance transport. Furthermore, it must serve as an accurate, factual assessment aiding billing partners in addressing any subsequent questions regarding the established criteria.

An ideal PCR narrative immerses the reader in the scene and elucidates the reason behind each treatment decision. When drafting a narrative, consider the following:

• Be thorough but straightforward. – Describe what happened in a logical order, incorporating patient statements, a description of the surroundings, and medical observations. Include the decision-making process that led to action regarding treatment and transport. Employ quotes when appropriate.
• Maintain accuracy and clarity. – Write professionally, avoiding irrelevant comments, personal viewpoints, wordplays, and humor. Proofread your narrative to eliminate incorrect grammar, inaccurate acronyms, and ambiguous language. These errors could potentially alter the narrative’s meaning and lead to unnecessary confusion.
• Ensure completeness and consistency throughout the document. – Verify that all requisite information aligns with your agency’s standards. Remember to disclose essential patient data, fractional mileage, and necessary signatures verifying that ambulance services were provided.

PCR narrative example

• PCR narrative example for transporting an unresponsive patient:
Unit (name and number) dispatched to a (nature of dispatch). The patient was a (patient description, e.g., age and gender) presenting (reported symptoms) reported by (reporting party, e.g., bystander, husband, daughter). (Include any additional details informed by dispatch, if applicable). Unit (name and number) en route at documented time (with lights and sirens, if applicable).

The patient was found (location and position, e.g., lying in bed in the bedroom). Patient was unresponsive and (details of medical assessment; include symptoms, trauma observed, skin tone, and body temperature). Vitals assessed as noted.

Crew member performed the initial assessment while the patient was (location and position). The assessment observed (details of medical condition). (Number of) crew members performed (interventions*). Patient responded to the interventions in (include details).

The patient was moved to the stretcher (detail method, e.g., using draw-sheet, by walking with assistance) by (number of) crew members, then secured and moved to the ambulance. Once loaded in the ambulance, all vitals were reassessed. Unit (name and number) initiated a (type of transport) to (destination). During transport, the patient’s condition was (include details). Upon arrival at the destination, the crew went to (room number or other type of location). Patient was moved from the stretcher to (equipment) via (method). No further request from the staff. Unit (name and number) clear.

*Always list all interventions performed and supplies used. Disclaim elements such as duration of a manual CPR and medication dosage. If possible, include the reason behind your decision to perform (or not) each intervention.