EMS Patient Care Report (911 Response)

Incident/ePCR Number: [Incident/ePCR number] Date of Service: [Local date] Agency/Unit: [Agency name / Unit identifier] Crew: [Crew names with credentials and roles] Response Mode: [emergent / non-emergent]

Response Times

(Use local time for all entries.)

• Unit Dispatched: [Time]
• Unit En Route: [Time]
• Arrived Scene: [Time]
• Patient Contact: [Time]
• Left Scene: [Time]
• Arrived Destination: [Time]
• Transfer of Care: [Time]
• Staging/Delays: [Reason and duration] (Only include if staging or delays occurred.)

Scene Assessment

[Scene safety status and hazards; patient position and location when found; general impression of distress and acuity; mechanism of injury or nature of illness with relevant details (trauma kinematics, protective devices, fall height; or medical onset circumstances); bystander interventions prior to EMS arrival and their outcomes] (Write as a concise narrative paragraph.)

Patient Information

Name: [Patient full name / Unknown adult male / Unknown adult female] DOB/Age: [DOB or estimated age] Sex: [Sex]
Information Source: [patient / family / bystander / ID / facility staff / law enforcement] (If demographics unobtainable, state reason.)

Consent & Legal Status

[implied / verbal / written] consent obtained. (For routine care/transport, this single line is sufficient.)

Refusal of Care/Transport

(Only include this subsection if patient refused care or transport.)

[Orientation and mental status findings supporting capacity; risks, benefits, and alternatives explained; return precautions provided; who will monitor patient; signatures obtained or reason unable to sign]

Advance Directives

(Only include this subsection if advance directives present or affect care.)

[DNR/POLST presence and how verified; resuscitation decisions made and rationale]

Chief Complaint & Primary Impression

Chief Complaint: "[Patient's own words]" (Note if dispatch complaint differs.)
Primary Impression: [medical / trauma / behavioral / OB / pediatric] — [Working diagnosis or suspected condition with supporting findings]

History of Present Illness

[Onset and time course; provocation/palliation; quality of symptoms; radiation; severity with pain scale; timing and duration; associated symptoms; pertinent negatives actually denied by patient; time-critical timestamps (symptom onset, last known well, time of injury, time of ingestion); relevant functional baseline] (Write as a coherent OPQRST-style paragraph.)

Past Medical History (SAMPLE)

• Allergies: [Allergies with reaction types / NKDA] (Document NKDA only if actually assessed.)
• Medications: [Medication list with focus on high-risk meds: anticoagulants, insulin, opioids/benzodiazepines, cardiac medications] (Attribute source.)
• Past Medical/Surgical History: [Relevant conditions and surgeries]
• Last Oral Intake: [Time and type] (Include when relevant to presentation.)
• Events Leading Up: [Pertinent recent events or exposures] (Include if relevant.)

Assessment Findings

Primary Survey

• General Impression: [Criticality, distress level, work of breathing, skin signs]
• Airway: [patent / compromised]; [Interventions if any]
• Breathing: [Rate, effort, lung sounds, SpO2]
• Circulation: [Pulse quality and rhythm, skin findings, bleeding, perfusion status]
• Neuro: [AVPU / GCS with components]; [Pupils]; [Focal deficits]

Focused/Secondary Exam

(Scale depth to acuity. Include pertinent negatives only if actually assessed.)

• [Head/Face/Neck findings]
• [Chest/Cardiac/Lung findings]
• [Abdomen/Pelvis findings]
• [Back/Spine findings]
• [Extremities with circulation/motor/sensory]
• [Detailed neuro exam if indicated: stroke scale elements, cranial nerves, motor/sensory]
• [Skin: color, temperature, moisture, wounds]

Vital Signs

(Present as time-series showing trends. Minimum two sets for transports: initial and pre-arrival.)

• Set 1: [Time] — HR [Value, rhythm if monitored]; BP [Value, method]; RR [Value]; SpO2 [Value on room air / device and flow]; Pain [0–10]; GCS/AVPU [Score]; Glucose [Value] (if indicated); ETCO2 [Value] (if obtained)
• Set 2: [Time] — HR [Value, rhythm]; BP [Value]; RR [Value]; SpO2 [Value and O2 delivery]; Pain [0–10]; GCS/AVPU [Score]; Glucose [Value] (if obtained); ETCO2 [Value] (if obtained)
• Additional Sets: [Repeat format as needed]
• Fewer vitals obtained due to: [Reason: CPR in progress / patient agitation / equipment failure / brief scene time] (Only include if fewer than expected vitals obtained.)

Diagnostics

(Include only diagnostics actually performed.)

• 12-Lead ECG: [Time obtained]; [Provider interpretation]; [Transmission status and confirmation]
• Point-of-Care Testing: [Test and result with time]
• Clinical Scales: [Scale used and score; criteria met] (e.g., stroke scale, trauma triage, sepsis screen)

Treatments & Interventions

(Chronological, time-stamped log. Each entry: time, intervention, dose/route/device/settings, indication linked to finding, response with objective measures, complications.)

• Airway/Respiratory: [Time] — [Intervention: O2 delivery / suctioning / nebulizer / CPAP / advanced airway]; [Device and settings]; [Indication]; [Response]; [Complications]
• Vascular Access: [Time] — [IV / IO]; [Site and side]; [Gauge]; [Attempts]; [Confirmation and patency]
• Medications Administered: [Time] — [Medication, dose, route, rate]; [Indication]; [Response]; [Adverse events]
• Medications Considered but Withheld: [Medication] — [Rationale] (Only include if decision explicitly made and relevant.)
• Other Procedures: [Time] — [Procedure]; [Site/device/settings]; [Indication]; [Response]; [Complications]

No prehospital interventions beyond assessment and monitoring. (Use this statement only if no treatments performed.)

Clinical Course & Reassessment

[Time-anchored narrative: response to treatments with objective measures (vital sign changes, SpO2 improvement, pain score reduction); changes in patient condition; medical control contact if obtained (time, physician, orders received)] (Link reassessment findings to vital signs trend.)

Transport & Destination

Transport Decision: [transported / treated-and-released / patient refusal / no patient contact]
Priority: [emergent / non-emergent] — [Rationale]
Destination: [Facility name and type] — [Rationale; specialty center criteria met if applicable; bypass/diversion and reason if applicable]

Transport Details: [Patient position; restraints/seatbelts; airway management during transport; companions; infection control measures] (Include details relevant to transport.)

Handoff

Transfer of Care Time: [Time] Receiving Clinician: [Name and role]

Situation: [Who the patient is and why EMS was called]

Background: [Key HPI; relevant PMH; medications; allergies]

Assessment: [Current status; key findings; vital signs; working impression]

Recommendation: [Treatments given and response; ongoing concerns; pending issues]

Continuity: [Lines/tubes in place; medications given with times; ECG/data transmitted; patient belongings]

Patient Condition at Transfer

[stable / unstable] — [Current vitals and mental status at handoff]

Medical Necessity Statement

[Concise paragraph explaining why ambulance transport was medically necessary: specific condition-related needs (immobility, monitoring, oxygen requirement, altered mental status, hemodynamic instability, need for restraints, emergency treatment); why alternative transportation was unsafe or inappropriate; origin and destination addresses]

Attestation

Provider Signature: [Name, credential] — [Date] [Time]
Patient/Representative Signature: [Name and relationship] — [Date] [Time] (If unable to sign, document method and reason.)
Witness Signature: [Name and role] — [Date] [Time] (Include if required by agency policy.)