D: Medic 1 was dispatched to an apartment complex for an assault. Medic 1 responded with lights and sirens, but staged for law enforcement until given the approval to arrive on scene.
C/C: "Nothing happened. I just fell into the mirror by accident."
Hx: EMS staged two blocks away from the scene until law enforcement was able to take control of the scene and allowed EMS to arrive on scene. EMS arrived on scene at the same time as the fire department. EMS noticed that a man, later realized to be the patient's husband, was sitting in a police car. Upon making introductions, EMS discovered that the patient is a 35-year-old female. While actively crying, the patient explained that about 20 minutes prior to EMS arrival, she and her husband were having a "heated discussion" and the neighbor "misread the situation" and called the police. EMS asked the patient how she got the laceration on her head and the patient explained that she was trying to walk away during the argument and her husband grabbed her arm. She explained that as she pulled away, she tripped over a coffee table, causing her to fall into the mirror and smashed her left cheek/face against the mirror, slicing her head on it. The patient denies any allergies to medications, medications taken, or medical history. The patient denies any interventions taken prior to EMS arrival.
Assessment: Patient denied all physical assessments, so EMS only obtained a visual assessment. Patient is AxOx4 to person, place, time, and event with a GCS of 15. Patient was willing to answer EMS questions. Patient has a patent airway and can speak to EMS in full sentences. Patient skin is pink and dry. External bleeding noted by EMS due to an approximate 2 inch laceration above her left eye and a small tear to her left lower lip. No other external bleeding or DCAP-BTLS noted by EMS on patient's visible body (tshirt, long leggings). Patient's breathing is adequate. Patient only describes a sharp-pain headache and rates her pain a 6/10. The patient says that closing her eyes helps with the headache. EMS asked if her pain radiated anywhere else and the patient reported that she also had neck pain, but would not allow EMS to physically assess C-spine for DCAP-BTLS. No injuries noted on visual inspection of neck.
Rx: No treatment provided by EMS. Patient denied treatment, vitals, physical assessment, and transport. Patient condition remained stable and unchanged throughout EMS scene time.
Transport: Patient refused transport. EMS explained to the patient that it is in her best interest to be transported to the hospital by EMS. The patient refused. EMS explained to the patient that EMS is not clearing her from any injury or illness, secondary to this incident. The patient understands. EMS explained to the patient that secondary symptoms relating to head and neck injuries can occur, ranging from serious injury through the possibility of death. The patient understands. EMS encouraged the patient to call EMS again should she notice any symptoms out of the ordinary arise and if her current symptoms do not subside. A refusal form was obtained from the patient by EMS, along with a witness signature by law enforcement.
I: Possible head injury secondary to assault
Student Name
Texas EMS School
April 20, 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.