An EMS patient care report, or PCR, records one call from dispatch to transfer of care: the times, what the crew found, what they did and when, and where the patient went. Copy the free template, see a STEMI taken to a PCI center and a fall where the patient refused transport, and check what goes in each part.
Blank patient care report template
FreeEMS PATIENT CARE REPORT Incident number and date: [Number, date] Unit: [Unit number and level: basic or advanced life support] Crew: [Names, certification levels, and roles: lead, driver, and others who gave care] Other agencies: [Fire, police, first responders, or none] Location: [Address and type of place] CALL TIMES Call received: [Time] Dispatched: [Time] En route: [Time] On scene: [Time] Patient contact: [Time] Departed scene: [Time, or not transported] At destination: [Time] Transfer of care: [Time] Back in service: [Time] PATIENT Name: [Name] Age, sex, and date of birth: [Age, sex, date] Weight: [kg, stated or estimated] Language: [Primary language; interpreter used, or none] DISPATCH AND SCENE Dispatch reason: [The nature of the call as dispatch gave it] Response: [Emergency or non-emergency] Scene: [Safety, where and how the patient was found, mechanism, and who was there] Care before arrival: [Bystander or first responder care, and medicines the patient took] CHIEF COMPLAINT [In the patient's words, and for how long] HISTORY: OPQRST Onset: [When it started, and what the patient was doing] Provocation: [What makes it better or worse] Quality: [In the patient's words] Region and radiation: [Where it is, and where it spreads] Severity: [0 to 10] Time: [How long; constant, or coming and going] HISTORY: SAMPLE Signs and symptoms: [Associated symptoms, and the negatives that shaped care] Allergies: [Drug and other allergies, with reactions] Medications: [Current medicines, anticoagulants, and anything taken for this problem] Past history: [Conditions and surgeries that bear on this call] Last oral intake: [Time, and what] Events: [What led up to the call] Source of history: [Patient, family, bystander, or records] ASSESSMENT Primary survey: [Airway, breathing, circulation, disability, exposure, and anything fixed at once] Level of consciousness: [AVPU, or GCS with eye, verbal, and motor scores] Exam: [Focused or head-to-toe findings] Vital signs: [Time; BP, HR, RR, SpO2 on room air or oxygen, glucose, temperature, pain, GCS; a set at contact, after each treatment, and before handover] Monitoring: [Rhythm, 12-lead times and interpretation, EtCO2] Field impression: [Primary impression, and any secondary ones] INTERVENTIONS [Time: intervention, dose, route, who did it, and the response] Withheld: [Medicine or procedure considered and not given, and why] NARRATIVE [The call in SOAP, CHART, or time order, written so another clinician could reconstruct it] TRANSPORT Decision: [Transported, treated and released, refused, or no patient found] Destination: [Facility, and why: closest, specialty center, patient choice, or protocol] Pre-alert: [Time, who took it, and what was sent] Mode and position: [Emergency or non-emergency; position, restraints, and who rode along] Condition en route: [Changes, repeat vital signs, and what was done] TRANSFER OF CARE Received by: [Name and role] Verbal report: [What was handed over] Left with receiving staff: [ECGs, medication list, belongings, written summary] Condition at handover: [Last vital signs, with the time] REFUSAL, WHEN CARE OR TRANSPORT IS DECLINED Capacity: [Orientation, GCS, glucose, signs of intoxication or head injury; understands, applies it to self, weighs options, and chooses consistently] Offered and declined: [Each part of care or transport the patient declined] Risks explained: [The specific risks, in plain words, and the patient's words back] Advice given: [Where to get care, warning signs, and to call 911 at any time] Medical control: [Contacted or not, as protocol requires; name, time, and advice] Left with: [Who stayed with the patient] SIGNATURES Lead provider: [Name, certification, and time the report was completed] Crew: [Names and certifications] Receiving clinician: [Name and signature, or the patient and a witness for a refusal]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Advanced life support crew, 911 call to a home, emergency transport
Incident 26-118402. Medic 14, advanced life support: Paramedic Dana Whitfield, lead and attending; EMT Luis Romero, driver. Engine 7 on scene to help lift. Call received 06:38, dispatched 06:39, en route 06:40, on scene 06:48, patient contact 06:50, departed 07:03, at destination 07:21, transfer of care 07:24, back in service 07:58.
Dispatched emergency for “chest pain, 67-year-old male, conscious and breathing,” called in by his wife. Single-family home, scene safe. Found sitting on the edge of his bed, pale and sweaty, a hand on his chest. No care before arrival; no aspirin taken.
“It feels like someone is sitting on my chest.” 45 minutes. Onset 06:05 while carrying the recycling bins to the curb; sat down and it didn’t ease. Not changed by rest, breathing, moving, or pressing on the chest. Heavy pressure in the center of the chest and upper abdomen, spreading to the jaw, not to the back. 8 out of 10, constant. Nauseated, sweaty, lightheaded on standing; not short of breath, no fainting. Allergies: penicillin, rash. Medications: metformin, lisinopril, atorvastatin; no anticoagulants; no sildenafil or tadalafil in the past 48 hours. History: type 2 diabetes, high blood pressure, high cholesterol; quit smoking 10 years ago; no known heart disease. Last ate toast and coffee at 05:45. History from the patient, confirmed by his wife.
Airway clear, breathing unlabored, radial pulse slow and weak, skin pale, cool, and clammy. Alert, GCS 15. Neck veins distended sitting up at 45 degrees; lungs clear on both sides; no leg swelling. 06:52: BP 92/58, HR 54, RR 18, SpO2 95% on room air, glucose 168 mg/dL (9.3 mmol/L), pain 8 out of 10. 12-lead at 06:55: sinus bradycardia at 54; ST elevation of 3 mm in III and 2 mm in II and aVF, with reciprocal ST depression in I and aVL. Right-sided leads at 06:58: ST elevation of 1.5 mm in V4R. 07:08: BP 100/62, HR 56, SpO2 96% on room air, lungs clear. 07:17: BP 108/66, HR 60, RR 16, SpO2 96% on room air, pain 7 out of 10. Field impression: inferior STEMI with right ventricular involvement.
06:54, monitor and 12-lead electrodes placed by Romero, read by Whitfield. 06:56, aspirin 324 mg, four 81 mg tablets chewed, given by Whitfield. 06:59, defibrillator pads placed for an inferior STEMI with a slow heart rate. 07:01, in the ambulance, IV 18 gauge in the left antecubital fossa, first attempt, by Whitfield; normal saline 250 mL bolus. BP 100/62 after it, lungs still clear, so a second 250 mL at 07:09; BP 108/66 at 07:17. Oxygen not given: SpO2 95% or above throughout. Withheld: nitroglycerin, for right ventricular involvement on V4R and a systolic BP of 92. No opioid given while the BP was low.
S: 67-year-old man with heavy pressure in the center of the chest and upper abdomen since 06:05, spreading to the jaw, 8 out of 10, with nausea and sweating. Diabetes, high blood pressure, high cholesterol. Penicillin allergy. No anticoagulants or erectile dysfunction drugs. O: Pale, clammy, alert. BP 92/58, HR 54, SpO2 95% on room air. Neck veins distended, lungs clear. 12-lead at 06:55: ST elevation in II, III, and aVF, reciprocal depression in I and aVL; ST elevation of 1.5 mm in V4R. A: Inferior STEMI with right ventricular involvement; low BP from the right ventricular infarct, so preload-dependent. P: Aspirin 324 mg chewed at 06:56. Nitroglycerin withheld for the right-sided involvement and low BP. Pads placed. Saline 250 mL twice from 07:01; BP rose to 108/66 with lungs clear. STEMI pre-alert and ECG sent at 07:00. Emergency transport to Bayview Medical Center, a PCI center, past a closer hospital with no cath lab. Care handed to the cath lab team at 07:24.
Emergency transport to Bayview Medical Center, a PCI center 18 minutes away, under the STEMI destination protocol; Lakeside Community Hospital, 6 minutes away, has no cath lab. Pre-alert by Romero at 07:00: STEMI, onset 06:05, right-sided involvement, BP 92/58, arriving in 20 minutes; 12-lead sent. Cath lab activated by the receiving emergency physician at 07:02. Supine on the stretcher, belted; his wife followed by car. En route: repeat 12-lead at 07:12 unchanged; BP rose with fluids as above; no rhythm change. Arrived 07:21, met at the door, and taken straight to the cath lab. Care transferred at 07:24 to Dr. Ana Prakash, interventional cardiologist. Verbal report: onset time, ECG and V4R findings, aspirin dose and time, why nitroglycerin was withheld, 500 mL saline and the BP response, penicillin allergy, metformin, last vital signs. Printed 12-leads and his medication list left with the team.
Dana Whitfield, Paramedic, report completed 07:52. Luis Romero, EMT. Received by Dr. Ana Prakash, signature taken at 07:24.
Advanced life support crew, 911 call to a restaurant, not transported
Incident 26-118977. Medic 9, advanced life support: Paramedic Omar Haddad, lead; EMT Nadia Brooks, driver. No other agencies. Call received 21:46, dispatched 21:47, en route 21:48, on scene 21:55, patient contact 21:56. Not transported: refusal signed 22:19, cleared the scene 22:22, back in service 22:23.
Dispatched emergency for “woman fell on the steps, conscious, bleeding from her hand,” called in by the restaurant manager. Wet stone steps outside the restaurant, scene safe. Found sitting on a bench with a friend, pressing a napkin to her right palm. Staff had given her ice for her knee.
“I slipped and scraped my hand and knee. I’m fine, honestly.” 15 minutes. Slipped on the second-to-last step at 21:40 and fell forward onto both hands and her right knee. No head strike or loss of consciousness, confirmed by her friend, who saw the fall. No neck or back pain, and no dizziness or fainting before the fall. Right palm stings, 2 out of 10, worse when pressed. Allergies: none known. Medications: oral contraceptive; a rescue inhaler for mild asthma, not used today. Last tetanus shot about 8 years ago. Dinner at 20:30 with one glass of wine. Leaving dinner in the rain when she slipped.
Alert and oriented to person, place, time, and what happened; GCS 15. Speech clear, gait steady, no smell of alcohol. Pupils equal and reactive. No scalp tenderness or bruising. No midline neck tenderness; turns her head fully without pain. Right palm: 3 by 2 cm graze with grit in it, oozing. Right wrist: no swelling or deformity, no tenderness over the end of the radius or at the base of the thumb, full movement, strong grip, normal sensation and capillary refill. Right knee: 4 cm graze, full movement, no swelling; walks without a limp. 21:59: BP 118/74, HR 86, RR 14, SpO2 99% on room air, glucose 94 mg/dL (5.2 mmol/L), pain 2 out of 10. 22:12: BP 116/72, HR 78, RR 14, SpO2 99% on room air. Field impression: grazes to the right palm and knee after a ground-level fall; no signs of fracture or head injury.
22:03, both grazes irrigated with saline and covered with non-stick dressings, by Brooks; most of the grit rinsed out, a few specks left deep in the palm. Ice pack for the knee. Accepted. No medicines given.
Transport to the emergency department offered at 22:08 and again at 22:15, for wound cleaning and a wrist X-ray; declined. She wants her friend to drive her home. Capacity: oriented, GCS 15, normal glucose, no signs of head injury or intoxication. She explained the information back in her own words, said it applied to her, compared going now with going to an urgent care tomorrow, and gave the same answer each time. Risks explained: a wrist fracture that a field exam can miss, infection from the grit left in the palm, and tetanus, since her last shot was about 8 years ago. Her words: “If my wrist swells or the base of my thumb hurts, I’ll get an X-ray. I’ll get the grit out and a tetanus shot tomorrow.” Advice: urgent care or her primary care clinician tomorrow, for the grit and a tetanus booster; call 911 or go to the emergency department for a swollen or misshapen wrist, numb fingers, spreading redness, pus, or fever. Written care instructions given. Medical control not contacted: a low-risk refusal under agency protocol. Her friend, Hannah Cole, will drive her home and stay the night.
C: Grazes to the right palm and knee after a slip on wet steps. H: 24-year-old woman fell forward onto her hands and right knee at 21:40; no head strike, confirmed by a witness. Mild asthma; last tetanus shot about 8 years ago. A: Alert, GCS 15, steady gait. Grazes with grit in the palm; no bony tenderness or deformity at the wrist or knee; circulation, sensation, and movement normal. Two sets of vital signs normal. R: Grazes irrigated and dressed at 22:03. T: Transport to the emergency department offered twice and declined after a capacity assessment and an explanation of the risks. Advice and written instructions given; refusal signed at 22:19 and witnessed. Left in her friend’s care.
Omar Haddad, Paramedic, report completed 22:41. Nadia Brooks, EMT. Refusal signed by the patient, Maya Torres, at 22:19; witnessed by Hannah Cole.
Who responded, where, and the clock for the whole call. Reviewers read the times first, to see how long each step took.
Avoid: Times written from memory at the end of the shift. Take them from the dispatch record and the monitor, so they match every other record of the call.
What you were sent to, and what you found when you got there. The two often differ, and the difference matters.
Avoid: Carrying the dispatch reason into your impression. A “fall” from dispatch may turn out to be a faint; write what you found.
Why the patient called, in their words, and the history in OPQRST and SAMPLE order, so nothing is skipped.
Avoid: Leaving out the negatives that shaped your care: no anticoagulants before a head injury, no erectile dysfunction drug before nitroglycerin.
What the crew saw and measured, with the time of each finding.
Avoid: One set of vital signs for a transported patient. Take a set at contact, after each treatment, and before handover.
Everything done, in time order: what, how much, by whom, and what changed.
Avoid: “Nitroglycerin withheld” with no reason. Name the finding that stopped you: low blood pressure, right-sided ST elevation, or a recent erectile dysfunction drug.
The call told in prose, in your agency’s format, so a reader can follow it from dispatch to handover without you there.
Avoid: A narrative that disagrees with the fields. If the narrative says aspirin at 06:56 and the medication field says 07:00, a reviewer can’t tell which is true.
Where the patient went, why there, how they did on the way, and who took over.
Avoid: “Care transferred to ED staff.” Name the person, the time, and what you reported.
When a patient declines care or transport: a record that they could make the decision, knew the risks, and had a plan.
Avoid: “Pt refused, signed.” A signature shows the form was signed, not that the patient understood. Write the conversation.
Who wrote the report, who received the patient, and when the report was finished.
Avoid: Changing a finished report so the edit can’t be seen. Add an addendum with the date, time, and reason.
An aspirin charted before patient contact, or a 12-lead after arrival at the hospital, makes a reviewer doubt every other time. Check that each intervention falls between contact and transfer of care.
If a protocol medicine wasn’t given, write why: the blood pressure, the ECG finding, the allergy, or the drug the patient had taken. Otherwise it reads as missed care.
“Fluid bolus given” leaves the reader guessing. Write the repeat blood pressure, lung sounds, or pain score that shows what happened next.
Record the orientation, GCS, glucose, and signs of intoxication or head injury, then how the patient showed they understood the risks. A signature on its own proves little.
Write the narrative from the structured fields, or check one against the other before you sign. Two versions of the same call help no one.
Vero Scribe writes the patient care report in your template from your dictation after the call, or from the conversation with the patient, with their consent. You review and edit every section, then copy it into your ePCR or export it to Word or PDF. Vero works in 60+ languages.
The call details and times, the crew, the dispatch reason and scene, the chief complaint, the history in OPQRST and SAMPLE order, the assessment with at least two timed sets of vital signs, every intervention with its time, dose, response, and who did it, a narrative, the transport decision and destination, changes en route, the transfer of care, and signatures. Add a refusal section when the patient declines care or transport.
S: what the patient and bystanders told you, including the chief complaint, OPQRST, and SAMPLE. O: what the crew saw and measured, with timed vital signs and ECG findings. A: your field impression and the reasons for it. P: what you did, with times, doses, and responses, then the transport, destination, and who took over. Keep it consistent with the structured fields.
The one your agency requires. SOAP groups facts by kind: told, found, concluded, done. CHART and DCHART follow the call in order, from dispatch to transport. A time-ordered narrative suits long calls where the patient changes. Whatever the format, a reader should be able to reconstruct the call from it.
Record the patient’s orientation, GCS, glucose, and any signs of intoxication or head injury; how they showed they understood and weighed the risks; the specific risks you explained and their words back; what care they accepted and declined; the advice given; who stayed with them; any medical control contact your protocol requires; and the signatures. If they won’t sign, write that, and have a witness sign.
Yes. Copy it, or download it as a Word or text file. No account needed.
Notes for the emergency department, where your patients are handed over.
The DCHART and DCHARTE formats, with worked narratives.
The clinic visit that ends with a 911 call and a transfer.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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