Important Notes
Hospital narratives may be shorter than EMS narratives, and while that is understood, students are still expected to gather as much information as possible. It is reasonable to assume that if you are able to take vital signs or perform an assessment, intervention, or treatment, you can also ask questions about why the patient is there for your history section and gather an appropriate assessment.
Make use of your nurses as resources, and it is always a good idea to inform them at the start of your shift that you are required to document every patient you see so they are aware. Please also note that many hospitals do not allow students to complete patient documentation near patients or at the nurse’s station. Halfway through and toward the end of the shift, speak with your preceptor and ask if you can step away to the breakroom for approximately 15–20 minutes to complete your documentation in the portal, explaining that it must be entered before you obtain signatures and evaluations for patient credit.
Example
D: N/A
C/C: "I feel really weak and shaky."
Hx: EMS student entered the ER room as the transporting EMS crew was transferring the patient from the stretcher to the hospital bed. Patient is a 58-year-old male who was brought in by EMS for altered mental status. Report from EMS indicated the patient was found at home by a family member, who stated the patient became increasingly confused and diaphoretic over a short period of time. EMS obtained a blood glucose level of 23 mg/dL on scene. Upon transfer to the hospital bed, the patient appeared lethargic but was able to respond to simple questions. Patient reported feeling weak, dizzy, and “shaky” prior to EMS arrival. Patient stated he has a history of diabetes but was unsure if he had taken his medications or eaten recently. Further history regarding medications, allergies, and full medical history was limited due to the patient’s altered mental status and the EMS student transitioning care shortly after arrival.
Assessment: Patient is AxOx2 to person and place with a GCS of 14 (confused verbal response). Airway is patent. Patient is able to speak in short, delayed responses. Breathing is adequate with equal chest rise and fall. Lung sounds are clear and equal bilaterally. Radial pulses are present and regular. Skin is pale, cool, and diaphoretic. No signs of trauma or external bleeding noted. Patient appears lethargic with slowed responses. Blood glucose level reported by EMS prior to arrival was 23 mg/dL.
Rx: Care was initiated by transporting EMS prior to hospital arrival. Upon ER arrival, patient was transferred to hospital staff for continued management and placed on monitoring equipment. EMS student obtained a set of vital signs, which were assessed as: BP 132/78, PR 112, RR 11 unlabored, SpO2 96% RA. The transporting EMS crew had already obtained IV access but did not give other treatment, reportedly due to a short transport time. ER nurse administered 25g of D10 glucose and the patient's BGL improved to 135 mg/dL. Patient mental status improved to AxOx4 to person, place, time, and event with a GCS 15. No additional treatment was provided by EMS student.
Transport: Patient arrived to Hospital ER via ambulance. Patient was transferred from EMS stretcher to hospital bed by EMS crew and ER staff via drawsheet pull x4. Verbal report was given to receiving RN. Disposition unknown due to EMS student moving onto another patient.
I: Hypoglycemia
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.