Please review each linked article below for examples outlining the specific documentation expectations for each type of patient. Students are expected to complete a Patient Care Report (PCR), including a detailed narrative in DCHARTI format, for every patient encounter during a clinical/field or Capstone shift.
- Medical Narrative Example
- Trauma Narrative Example
- Refusal Narrative Example
- Interfacility Transfers (on EMS Shift) Narrative Example
- Cancellation Narrative Example
- It is not mandatory to document cancellations. The example is primarily available as an educational tool to prepare you for what will be expected for the profession.
- Hospital Shift Narrative Example
Disclaimer: Everyone writes PCRs a little differently. As long as your information is placed in a section that makes sense, is documented in DCHARTI format, and you obtained all pertinent information, that is acceptable. PCRs should tell a story. If your PCR is subpoenaed one day, you should be able to remember that patient based on your report. If it isn't documented, it did not happen. Additionally, please ensure you follow all procedures for checking in to your shift, log all patient encounters before checking out, and complete all end-of-shift requirements prior to leaving the site.