EMS 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]