D: Medic 1 was dispatched to an apartment complex for a patient with abdominal pain. Medic 1 responded with lights and sirens.
C/C: "My stomach hurts so bad."
Hx: EMS arrived on scene at the same time as the fire department. EMS knocked on the patient's front door and the patient yelled for EMS to enter the apartment. EMS noticed that the patient was sitting on her couch in the fetal position, holding her stomach, and grimacing in pain. EMS notes a pile of vomit on the floor next to her. Upon introduction, EMS discovered that the patient is a 24 year old female. The patient explained that about 15 minutes prior to EMS arrival, she was doing a home workout and got a sudden sharp pain in her stomach. She then describes getting really nauseous, but not being able to get to the bathroom, so she fell onto the couch and vomitted. EMS asked if it was possible for the patient to be pregnant and the patient reported that it is possible as she is sexually active, but she recently started spotting so she does not believe she is pregnant. EMS asked if she had been late on her period in the last few months and the patient stated that she skipped the previous two months. Patient does not report any abnormal bowel movements. The patient denies any allergies to medications, medications taken, or medical history. The patient denies any interventions taken prior to EMS arrival.
Assessment: Patient is AxOx4 to person, place, time, and event with a GCS of 15. Patient has a patent airway and can speak to EMS in full sentences, though she would hesitate mid-sentence when experiencing pain. Patient has bilateral radial pulses. Patient skin is pale and diaphoretic. No external bleeding noted by EMS. Patient's breathing is adequate and lung sounds are clear and equal bilaterally. Heart tones are normal. EMS did not note any abdominal distention during visual assessment and did not note abdominal rigidity on palpation. The patient felt pain on palpation in right lower quadrant. Patient rates her pain a 10/10. Abdominal sounds are normal in all four quadrants. The patient reports that the pain feels better when she applies pressure to her lower stomach. EMS asked if her pain radiated anywhere else and the patient reported that she also had a cramping sensation"down there", which EMS clarified verbally that the patient was indicating her genital region.
Rx: No treatment provided by EMS. EMS initiated rapid transport of the patient. Patient vital signs were monitored throughout transport. Initial vital signs on scene were: BP 150/86, PR 98, RR 18 unlabored, SPO2 98% on room air. Secondary vital signs upon arrival at destination were: BP 148/76, PR 92, RR 18 unlabored, SPO2 97% on room air. Patient condition remained stable and unchanged throughout transport.
Transport: Patient was ambulatory with assistance from couch to stretcher. Patient was secured to stretcher with all appropriate straps and loaded into the ambulance. Patient was transported to Hospital ER without incident in left lateral recumbent position, as per patient request. Patient was moved from stretcher to Hospital ER bed 7 via draw sheet pull x3. Radio report was given to receiving facility during transport. Report was given to the receiving RN upon arrival. All required signatures obtained by EMS.
I: Abdominal pain, pregnancy possible
Student Name EMTB
Texas EMS School
April 17, 2026
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.