EMS Trauma Patient Care Report

Date/Time of Incident: [Incident date and time] (Use 24-hour local time)

Agency/Unit: [Agency name and unit identifier]

Crew: [Crew names and roles]

ePCR/Incident #: [Identifier]

Patient: [Name / DOB / Age / Sex or "Unknown" with identification method]

Primary Complaint: [Standardized label, e.g., "MVC—multi-system trauma" / "GSW—torso" / "Fall—extremity injury"]

Times

Event	Time
Dispatched	[Time or "Not recorded"]
Arrived Scene	[Time or "Not recorded"]
Patient Contact	[Time or "Not recorded"]
Left Scene	[Time or "Not recorded"]
Arrived Destination	[Time or "Not recorded"]
Transfer of Care	[Time or "Not recorded"]

Scene Time: [Calculated HH:MM] Transport Time: [Calculated HH:MM] (Derive from times above if available)

Scene & Mechanism of Injury

Scene/Extrication: [Relevant hazards, extrication complexity if applicable] (Omit if unremarkable)

Mechanism of Injury: [Description with energy transfer indicators; restraint/helmet/airbag status if known; note source limitations such as "patient amnestic" or "no witnesses" when applicable]

Trauma Triage Criteria Met: [High-risk criteria / Moderate-risk criteria / EMS clinical judgment / None met] (Specify which criteria were met)

Assessment

Primary Survey ([Time]):

• Airway: [Patency, threats, adjuncts used]
• Breathing: [Work of breathing, breath sounds, chest wall findings]
• Circulation: [Major hemorrhage present/absent, skin signs, pulse quality, perfusion]
• Disability: GCS [E__ V__ M__ = __], pupils [size/reactivity], [focal deficits if present]
• Exposure: [Obvious injuries identified, temperature management if applicable]

Focused Trauma Assessment: [Injuries by body region with location, type, and severity; include pertinent negatives that affect triage or treatment decisions; document baseline neurovascular status distal to extremity injuries]

Interventions

(Document each intervention performed with time, site/location, and patient response. Omit categories not performed.)

Hemorrhage Control: [Time] [Method: direct pressure / wound packing / tourniquet] [Site] [Bleeding controlled: yes/no] (For tourniquets: specify device type, exact placement, time applied, distal pulse status)

Spinal Motion Restriction: [Indications assessed] [Decision and rationale] [Method used] (If SMR not performed despite high-risk mechanism, explicitly document why)

Vascular Access/Fluids: [Time] [IV/IO site and gauge] [Fluid type, volume] [Response]

Medications: [Time] [Drug, dose, route] [Indication] [Response]

Other Interventions: [Airway management, splinting, chest interventions, pelvic binder, other procedures as performed—include time, device/method, site, and response for each]

Pain Management: Baseline pain [0–10], [Intervention], Reassessment pain [0–10 at time]

Vitals

Time	BP	HR	RR	SpO2	ETCO2	GCS	Pain
[Time]	[Value]	[Value]	[Value]	[Value]	[Value]	[E/V/M=Total]	[0–10]
[Time]	[Value]	[Value]	[Value]	[Value]	[Value]	[E/V/M=Total]	[0–10]
[Time]	[Value]	[Value]	[Value]	[Value]	[Value]	[E/V/M=Total]	[0–10]

(Include initial vitals plus repeat sets after major interventions and at intervals during transport. Use "Unable to obtain" or "Not recorded" for missing required values.)

Transport & Disposition

Destination: [Facility name, type, trauma center level if applicable]

Transport Mode/Priority: [Ground / Air] [Emergent / Non-emergent]

Triage Rationale: [Criteria met; why this destination was selected over alternatives or why closest was appropriate; constraints affecting decision]

Trauma Alert: [Yes / No] [Time notified] [ETA provided]

Transfer of Care: [Receiving clinician/team] [Condition summary: airway, hemodynamics, bleeding control, neuro status] [Active interventions handed off with times]

Clinical Narrative:

[Chronological summary from dispatch through handoff: mechanism and initial presentation, key assessment findings, interventions with responses, transport course and handoff. Attribute reported information to source. Separate observed findings from clinical impressions. 1–3 short paragraphs.]