Patient Care Report Documentation

Status: Current

Effective date: August 24, 2026

Last revised: August 24, 2026

A patient care report (PCR) is expected for patient contacts that involve assessment, treatment, medication, transport, refusal, transfer of care, death or pronouncement, or another circumstance requiring documentation under department policy.

Complete the record before ending duty when practical. If operational conditions delay completion, finish it as soon as reasonably possible and preserve the relevant times and details.

Minimum content

Include, as applicable:

• patient information available through authorized systems;
• dispatch, response, arrival, contact, transport, and transfer times;
• scene conditions, hazards, and mechanism or nature of illness;
• chief complaint and relevant history;
• assessment and examination findings;
• vital signs and trends;
• diagnostics and results;
• clinical impression;
• treatments, procedures, and medications;
• dose, route, time, indication, and response for each medication;
• changes in condition and reassessment;
• transport decision, destination, and receiving handoff;
• final disposition; and
• a clear chronological narrative.

Use objective clinical language. Separate patient statements, witness information, provider observations, and clinical conclusions.

Refusal

Document decision-making capacity, the assessment offered and completed, findings and concerns explained, recommended care or transport, reasonably foreseeable risks, alternatives, the patient's decision, witnesses or consultation, and return precautions.

A signature or acknowledgment does not replace a capacity assessment or adequate explanation.

Death or pronouncement

Document the condition on arrival, assessment performed, resuscitation or reason it was not initiated, consultation or authority used, time recorded under policy, required notifications, scene transfer, and disposition of personal property.

Do not state a criminal conclusion unless it is separately established by the responsible authority.

Medication errors and protocol deviations

Record what occurred, the patient's condition, immediate corrective action, consultation, notification, disclosure required by policy, and continued monitoring. Do not alter or omit the record to conceal an error.

Complete any separate quality-review or incident form required by department policy. A transparent correction or supplement is preferable to rewriting material history.

Privacy and corrections

Include only information needed for patient care and department operations. Do not place out-of-character personal information in a PCR. Correct errors through the approved amendment or supplement process so the original record remains traceable.