By: David March, Training Officer, 2013-2014
Different calls will have different forms that most effectively get the information across. However, a good general form emerges from the popular acronym SOAP: Subjective, Objective, Assessment, (treatment) Plan. Here’s a summary:
Subjective: Introduce the patient and their condition. Include relevant history given by the patient and by bystanders (always noting the source of the information), and everything that led up to EMS being called. This information is likely to be the least scientific on your report, but it also can be absolutely critical to assessment of the patient further down the healthcare chain.
Objective: Here’s where you get to strut your EMS stuff. What examinations did you perform, and how did these turn out? Running through DCAPBTLS, did you notice anything odd about the patient, or is there anything that you would have expected to be unusual that turned out to be unaffected? This section is where you prove that you did you job thoroughly examining the patient for symptoms.
Assessment: We don’t provide diagnoses in EMS, but that doesn’t mean that were clueless about what is going on with a patient. If you suspect that something in particular is off with a patient, and it ties into your treatment plan, note it.
Plan: Once you gathered all your information about the patient’s condition, what did you do about it? Don’t forget that treatment plans can include everything from administering oxygen to moving them into a seated position. Your treatment plan should also include the patient’s disposition, as turning control over to a different agency should come from your expectation that there is something that agency can provide that you cannot.
PCRs are a record of all the information about the call, but this information will be confusing and misleading unless you organize it in a sensible fashion. Use your best judgment when organizing your narrative section, but if you’re unsure of how to proceed, SOAP is a good generic template. And please, take some time before you start writing. Talk to the other EMTs involved in the call, read over your notes and run through the call in your mind. Taking a few moments before you start can radically improve the quality of your report, as it gives you time to remember the details of the call, and to put them into an understandable order.