Patient Care Report ExamplesComplete PCR Templates for EMS

DISPATCH: Responded to 123 Main St for 62 y/o male with chest pain. Unit 45 dispatched at 14:32, en route 14:34, on scene 14:41.

PATIENT INFORMATION:
Name: John D.
Age: 62 years
DOB: 03/15/1962
Gender: Male
Weight: ~185 lbs

CHIEF COMPLAINT: "Crushing chest pain that started about an hour ago"

HISTORY OF PRESENT ILLNESS:
Patient states pain began suddenly while watching TV at approximately 13:30. Describes pain as 8/10 "crushing" sensation in center of chest with radiation to left arm and jaw. Associated with diaphoresis and shortness of breath. Denies nausea/vomiting. Patient took one aspirin 325mg prior to our arrival per 911 dispatcher instructions.

PAST MEDICAL HISTORY:
- Hypertension (10 years)
- Hyperlipidemia
- Type 2 Diabetes
- Previous MI (2019)

MEDICATIONS:
- Metoprolol 50mg BID
- Lisinopril 20mg daily
- Atorvastatin 40mg daily
- Metformin 1000mg BID

ALLERGIES: PCN (rash)

ASSESSMENT FINDINGS:
Time: 14:43
LOC: Alert and oriented x4
Airway: Patent
Breathing: 22/min, slightly labored
Circulation: Radial pulse present, weak and irregular

VITAL SIGNS:
14:43 - BP: 158/94, HR: 98 irregular, RR: 22, SpO2: 94% RA, BGL: 186
14:50 - BP: 152/90, HR: 92 irregular, RR: 20, SpO2: 98% O2, BGL: --
14:58 - BP: 148/88, HR: 88, RR: 18, SpO2: 99% O2, BGL: --

12-LEAD ECG: ST elevation in leads II, III, aVF consistent with inferior STEMI. Transmitted to receiving facility.

TREATMENT:
14:44 - O2 via NC @ 4L/min
14:45 - IV established, 18g L AC, NS TKO
14:46 - 12-lead ECG acquired and transmitted
14:47 - ASA 324mg PO (patient had taken 325mg prior)
14:48 - NTG 0.4mg SL x1, pain reduced to 6/10
14:52 - NTG 0.4mg SL x2, pain reduced to 4/10
14:55 - Fentanyl 50mcg IV for continued pain

TRANSPORT:
Left scene: 14:58
Arrived hospital: 15:12
Transported to: Regional Medical Center - Cath Lab notified, STEMI alert activated
Transport position: Semi-Fowlers
Transport priority: Emergent

NARRATIVE:
Unit 45 responded to single family residence for male with chest pain. Found patient sitting in recliner, appearing pale and diaphoretic. Patient alert, oriented, and able to provide history. Assessment revealed findings consistent with acute coronary syndrome. 12-lead confirmed inferior STEMI pattern. STEMI alert called to Regional Medical Center with cath lab activation. Patient received aspirin, oxygen, nitroglycerin with improvement, and fentanyl for pain management. IV access obtained. Patient transported emergent without incident. Care transferred to ED staff with verbal and written report.

CREW:
Paramedic: Smith, J. (Lead)
EMT-B: Johnson, M.

DISPATCH: Responded to I-95 NB MM 42 for MVC with injuries. Unit 23 dispatched at 09:15, en route 09:17, on scene 09:28.

PATIENT INFORMATION:
Name: Sarah M.
Age: 34 years
DOB: 07/22/1990
Gender: Female
Weight: ~140 lbs

CHIEF COMPLAINT: Neck pain, headache following MVC

MECHANISM OF INJURY:
Patient was restrained driver in moderate-speed rear-end collision. Airbag deployed. Patient ambulatory on scene. Moderate damage to rear of vehicle. Denies loss of consciousness.

HISTORY OF PRESENT ILLNESS:
Patient states she was stopped at traffic when struck from behind by another vehicle traveling approximately 35-40 mph. She reports immediate onset of neck pain and headache. Denies LOC, denies numbness/tingling in extremities. Pain is 6/10 in posterior neck, worsened with movement.

PAST MEDICAL HISTORY:
- Asthma (mild, intermittent)
- Anxiety

MEDICATIONS:
- Albuterol PRN
- Sertraline 50mg daily

ALLERGIES: NKDA

ASSESSMENT FINDINGS:
Time: 09:30
LOC: Alert and oriented x4, GCS 15 (E4V5M6)
Airway: Patent
Breathing: 16/min, unlabored, clear bilaterally
Circulation: Radial pulse strong, regular

HEAD/NECK: No visible trauma, tenderness to palpation over C5-C7 spinous processes, no step-off deformity
CHEST: Non-tender, equal rise and fall
ABDOMEN: Soft, non-tender
PELVIS: Stable
EXTREMITIES: No deformity, moves all extremities, pulses present x4

VITAL SIGNS:
09:30 - BP: 138/82, HR: 88, RR: 16, SpO2: 99% RA
09:40 - BP: 132/78, HR: 82, RR: 16, SpO2: 99% RA
09:50 - BP: 128/76, HR: 78, RR: 14, SpO2: 99% RA

TREATMENT:
09:31 - Manual C-spine stabilization initiated
09:33 - C-collar applied (regular size)
09:35 - Patient placed on long spine board with head blocks and straps
09:38 - Assessment completed

TRANSPORT:
Left scene: 09:42
Arrived hospital: 09:58
Transported to: Community Hospital ED
Transport position: Supine on LSB
Transport priority: Non-emergent

NARRATIVE:
Unit 23 responded to interstate for reported MVC. Arrived to find two-vehicle rear-end collision with moderate damage. Patient found standing outside vehicle with bystander support. Due to mechanism and complaint of neck pain, full spinal precautions initiated. Physical exam revealed midline cervical tenderness without neurological deficit. Patient immobilized on long board with cervical collar. Vitals stable throughout transport. No interventions required en route. Patient transported to Community Hospital without incident. Full report given to receiving RN.

CREW:
Paramedic: Williams, R. (Lead)
EMT-B: Chen, L.

DISPATCH: Responded to 456 Oak Ave, Apt 2B for diabetic emergency. Unit 12 dispatched at 07:45, en route 07:47, on scene 07:52.

PATIENT INFORMATION:
Name: Robert T.
Age: 58 years
DOB: 11/08/1966
Gender: Male
Weight: ~210 lbs

CHIEF COMPLAINT: Altered mental status, known diabetic

HISTORY OF PRESENT ILLNESS:
Wife called 911 after finding patient difficult to arouse this morning. She reports he took his usual insulin last night but ate very little dinner due to feeling unwell. This morning he was confused, diaphoretic, and unable to follow commands. No seizure activity witnessed.

PAST MEDICAL HISTORY:
- Type 1 Diabetes (30 years)
- Hypertension
- Chronic kidney disease stage 3

MEDICATIONS:
- Insulin glargine 40 units nightly
- Insulin lispro sliding scale with meals
- Amlodipine 10mg daily
- Losartan 50mg daily

ALLERGIES: Sulfa (hives)

ASSESSMENT FINDINGS:
Time: 07:54
LOC: Confused, oriented to person only, GCS 13 (E3V4M6)
Airway: Patent, no secretions
Breathing: 18/min, unlabored
Circulation: Radial pulse bounding, regular
Skin: Cool, pale, diaphoretic

VITAL SIGNS:
07:54 - BP: 168/92, HR: 102, RR: 18, SpO2: 97% RA, BGL: 38 mg/dL
08:02 - BP: 152/88, HR: 92, RR: 16, SpO2: 98% RA, BGL: 78 mg/dL
08:10 - BP: 144/82, HR: 84, RR: 14, SpO2: 99% RA, BGL: 124 mg/dL

TREATMENT:
07:55 - Blood glucose checked: 38 mg/dL
07:56 - IV established, 20g R hand, NS TKO
07:58 - Dextrose 50% 25g (50mL) IV push
08:00 - Patient becoming more alert
08:02 - Repeat BGL: 78 mg/dL
08:05 - Oral glucose gel 15g administered
08:10 - Repeat BGL: 124 mg/dL, patient A&Ox4

TRANSPORT:
Patient initially refused transport after glucose normalized. After discussing risks including potential for recurrent hypoglycemia given long-acting insulin on board, patient agreed to transport for evaluation.

Left scene: 08:18
Arrived hospital: 08:32
Transported to: University Hospital ED
Transport position: Semi-Fowlers
Transport priority: Non-emergent

NARRATIVE:
Unit 12 responded to apartment for diabetic emergency. Found 58 y/o male in bed, confused and diaphoretic. Wife at bedside provided history. Initial BGL critically low at 38 mg/dL. IV established and D50 administered with good response. Patient became alert and oriented within minutes. Repeat BGL showed appropriate response. Given potential for recurrent hypoglycemia with long-acting insulin, patient counseled on need for hospital evaluation and agreed to transport. No complications during transport. Full verbal report given to ED nurse.

CREW:
Paramedic: Anderson, K. (Lead)
EMT-B: Patel, S.

DISPATCH: Responded to 789 Pine St for difficulty breathing. Unit 31 dispatched at 16:22, en route 16:24, on scene 16:31.

PATIENT INFORMATION:
Name: Maria G.
Age: 28 years
DOB: 04/12/1996
Gender: Female
Weight: ~130 lbs

CHIEF COMPLAINT: "I can't breathe"

HISTORY OF PRESENT ILLNESS:
Patient reports progressive shortness of breath over past 3 hours after exposure to cat at friend's house. Has been using her rescue inhaler every 30 minutes without relief. Reports associated chest tightness and audible wheezing. Denies fever, productive cough, or recent illness. Last asthma hospitalization was 2 years ago.

PAST MEDICAL HISTORY:
- Asthma (severe persistent)
- Allergic rhinitis
- Previous intubation for asthma (2019)

MEDICATIONS:
- Fluticasone/Salmeterol 250/50 BID
- Montelukast 10mg daily
- Albuterol MDI PRN
- Cetirizine 10mg daily

ALLERGIES: Cats (triggers asthma), Shellfish

ASSESSMENT FINDINGS:
Time: 16:33
LOC: Alert, anxious, speaks in 2-3 word sentences
Airway: Patent
Breathing: 32/min, labored, accessory muscle use, tripod positioning
Circulation: Radial pulse rapid, strong
Lung sounds: Diffuse expiratory wheezes bilaterally, diminished at bases

VITAL SIGNS:
16:33 - BP: 142/88, HR: 118, RR: 32, SpO2: 88% RA, ETCO2: 32
16:40 - BP: 138/84, HR: 110, RR: 28, SpO2: 92% O2, ETCO2: 34
16:48 - BP: 132/80, HR: 102, RR: 24, SpO2: 95% O2, ETCO2: 36

TREATMENT:
16:34 - O2 via NRB @ 15L/min
16:35 - Albuterol 2.5mg + Ipratropium 0.5mg via nebulizer
16:36 - IV established, 20g L AC, NS TKO
16:38 - Methylprednisolone 125mg IV
16:42 - Repeat albuterol 2.5mg nebulizer
16:45 - Magnesium sulfate 2g IV over 10 min (started)

TRANSPORT:
Left scene: 16:50
Arrived hospital: 17:05
Transported to: Regional Medical Center ED
Transport position: High Fowlers
Transport priority: Emergent

NARRATIVE:
Unit 31 responded to residence for breathing difficulty. Found 28 y/o female in tripod position on couch, in obvious respiratory distress with audible wheezing. Patient has history of severe asthma with previous intubation. Reports cat exposure as trigger. Assessment revealed tachypnea, tachycardia, hypoxia, and diffuse wheezing. Aggressive treatment initiated including high-flow oxygen, back-to-back nebulizers, IV steroids, and magnesium. Patient showed gradual improvement during transport with improved oxygenation and work of breathing. Continuous monitoring maintained. Hospital notified of incoming asthma exacerbation. Full report provided to ED team.

CREW:
Paramedic: Thompson, J. (Lead)
EMT-B: Rivera, M.

DISPATCH: Responded to 234 Elm Street for pediatric seizure. Unit 17 dispatched at 11:08, en route 11:10, on scene 11:16.

PATIENT INFORMATION:
Name: Emma L.
Age: 2 years, 4 months
DOB: 08/03/2022
Gender: Female
Weight: ~28 lbs (per parent)

CHIEF COMPLAINT: Seizure activity, now post-ictal

HISTORY OF PRESENT ILLNESS:
Mother reports patient had generalized tonic-clonic seizure lasting approximately 2-3 minutes that stopped prior to EMS arrival. Patient has had fever (101.4°F per mom) for past 24 hours with runny nose and cough. No previous seizure history. Seizure involved whole body shaking with eyes rolled back. No cyanosis noted by mother. Patient is now sleepy but arousable.

PAST MEDICAL HISTORY:
- Full-term birth, no complications
- Up to date on immunizations
- No chronic medical conditions
- No previous seizures

MEDICATIONS: Acetaminophen given approximately 2 hours ago

ALLERGIES: NKDA

ASSESSMENT FINDINGS:
Time: 11:18
LOC: Post-ictal, sleepy but arousable, cries when stimulated
Airway: Patent
Breathing: 24/min, unlabored
Circulation: Radial pulse strong, regular
Skin: Warm, flushed, dry

PHYSICAL EXAM:
Head: Atraumatic, fontanelle flat
Eyes: PERRL, no nystagmus
Ears: TMs not visualized (not in scope of practice)
Throat: Not examined
Neck: Supple, no rigidity
Chest: Clear bilaterally
Abdomen: Soft, non-tender
Extremities: Moving all x4, no trauma

VITAL SIGNS (Pediatric Broselow: Yellow zone):
11:18 - BP: 98/62, HR: 142, RR: 24, SpO2: 98% RA, Temp: 102.8°F (rectal), BGL: 94
11:28 - BP: 96/60, HR: 132, RR: 22, SpO2: 99% RA, Temp: --, BGL: --
11:38 - BP: 94/58, HR: 124, RR: 20, SpO2: 99% RA, Temp: --, BGL: --

TREATMENT:
11:19 - Patient undressed for cooling
11:20 - Tepid cloth to forehead and axillae
11:22 - Ongoing monitoring, no further seizure activity
11:25 - Patient becoming more alert, interacting with mother

TRANSPORT:
Left scene: 11:32
Arrived hospital: 11:48
Transported to: Children's Hospital ED
Transport position: Car seat secured to stretcher (patient's own)
Transport priority: Non-emergent

NARRATIVE:
Unit 17 responded to residence for pediatric seizure. Arrived to find 2 y/o female in mother's arms, post-ictal but arousable. Mother witnessed generalized seizure lasting 2-3 minutes that self-resolved. Patient has had URI symptoms with fever past 24 hours. Assessment consistent with simple febrile seizure - generalized, brief (<5 min), single episode in febrile child age 6 months to 5 years. No further seizure activity observed. Patient progressively more alert during our contact. Transported in car seat per protocol. Patient calm and interactive by arrival. Mother rode in front seat per policy. Complete report given to pediatric ED nurse.

CREW:
Paramedic: Garcia, A. (Lead)
EMT-B: Kim, D.