EMS Communication and Documentation

EMS Communication and Documentation
Table of Contents
Introduction 4
Course Overview and Objectives 4
Communications Systems 5
Communication 5
Communication Terms 6
Equipment Maintenance 8
Radio Communications 8
Communicating With Dispatch 8
Guidelines for Effective Radio Communication 9
Case Study - Communications Breakdowns Make Bad Situations Worse 10
Communication En Route 12
Medical Direction 12
The Patient Hand-off 14

Verbal Report to Hospital Staff 14
Patient Handoff – SBAT 14
Patient Handoff – MIVT 15
Interpersonal Communication 15
Interpersonal Communication Skills 15
Pre-Hospital Care Report 16

Importance of Documentation 16
Legal Document 17
Quality Improvement Instrument 18
Research 18
Paperless Reporting or ePCRs 19
The PCR Form 19

Document Basic Patient Information 20
Narrative Section Tips 20
Patient Confidentiality 21
ePCR Errors 21
Patient Signatures 22
Page 2 of 28 © Vector Solutions

Consent & Refusal 22

Types of Consent 22
Types of Refusals 23
Special Situations and Considerations 24

Social Media 24
Events 25
Multiple Casualty Incidents (MCI) 25
Special Situation Reports 25
Conclusion 25
Final Thoughts 25
Summary (summary.cfm) 26
References 27
Resources 28
References 28
Subject Matter Expert 28

Paul Costello 28

Introduction
Course Overview and Objectives
Communications is at the center of what and how, we, as emergency responders fulfill our
professional responsibilities. How we listen and interact with 9-1-1 calling parties, dispatchers,
co-responding agencies, allied health professionals, and others will determine whether those
interactions are positive and successful or negative opportunities. Communications isn’t related
solely to the verbal realm. There is also non-verbal and written communication that will also be a
part of every response that we go to.
When we assess and treat a patient, the care that was provided can potentially go for naught if
we fail to communicate all that we saw, did, and why we did those things to the staff at the
patient’s receiving facility.
For fire rescue and EMS, communications begin when the call comes into the public safety
access point or PSAP for 9-1-1.
It continues during the pre-dispatch scripted questioning, during the dispatch/response phase
and well after the call has actually ended. Therefore, knowing that communications lie at the
heart of what we do professionally, fire rescue, EMS, and first responders of all stripes must
have excellent communication skills now more than ever before. Communications link
everything that we do. How we communicate has professional and potentially even personal
outcomes. Helping you to be more effective and efficient in this vital skill is the goal of this
course.
After successfully completing this course, you will be able to:
● Describe the elements of a public safety communications system
● Explain the importance of effective communication and documentation of patient

information in the pre-hospital setting
● Identify interpersonal communication skills that should be used to interact with the
patient, family, and individuals from other agencies while providing patient care
● Identify the primary components of the Pre-hospital Care Report (PCR)and its variety of
functions for patient care
● List the types of patient consent and refusal of care
● Identify the importance of providing accurate documentation (oral and written) in

substantiating an incident

Communications Systems
Communication
Communications systems are how the public reaches emergency services and how emergency
response personnel communicate with dispatch, medical direction, hospitals, other public safety
agencies and each other.
When someone has a medical emergency, they pick up the phone and dial 911. The public
takes it for granted that their call will be answered and help will be sent immediately. The
systems are increasingly complex and handle hundreds of millions of 911 calls annually.
In EMS systems, the call is typically answered by an emergency medical dispatcher, trained to
analyze, prioritize and process calls while maintaining radio and mobile computer terminal
(MCT) contact with responders to ensure safe, efficient and effective responses.1 Maximizing
fleet efficiency, sending the correct resources, and minimizing response times, computer-aided
dispatching systems are a staple across the country.
The 911 system was implemented in the 1960s, and the technology was based on wired
phones (i.e., landlines).2 Today, people communicate via wireless phones, text messages,
smartphones, video chat, Internet Protocol (IP)-enabled devices and other methods. The
expectation remains the same – dial 911 and gets help. However, the communications systems
are in a state of an overhaul.
The changes to the 911 system were designed to make emergency communications compatible
with IP-enabled devices and enable responders to accept and transmit text, data, and video
over public safety communications systems (i.e., Next Generation 911); and to ensure that
location information, accurate within 50 meters (150 feet) of the 911 call, is automatically
transmitted to the communications center or public safety answering point from whatever device
is used to access 911.
As we mentioned, 911 is a concept that was implemented in the 1960s from a late 1950s
position statement from the International Association of Fire Chiefs. It took the better part of fifty
years for 97% of the nation to be covered by 911. Ongoing telecommunications changes on the
part of the customers and the companies themselves will continue to be a part of the
everchanging communications landscape for EMS and fire rescue personnel.
All radio operations are regulated by the Federal Communications Commission (FCC). The FCC
assigns (via certified frequency coordinators, such as the Association of Public-Safety
Communications Officials International) and licenses radio frequencies for use by EMS and
other public safety agencies.

Communication Terms
As an EMS provider, it’s important to be able to communicate with your radio technicians when
something goes wrong. Understand the meaning of basic communication terms is vital to
effectively communicating. Click on each term to learn more.
Portable
The handheld unit you carry with you.
Mobile radio
A vehicle-mounted radio.
MCT
This stands for the mobile computer terminal and may come in the form of a laptop computer
that is often ruggedized or even a tablet computer. Dispatchers transmit up to date call
information, notes, EMD interrogation findings, pre-fire plans, route mapping and much more
through them.
Base station
Generally, it refers to a radio system's main transmitter. Sometimes, the term is applied to a
repeater, which receives a transmission and retransmits it at higher power.
Analog
Traditional analog radios process sounds into patterns of electrical signals that resemble sound
waves.
Digital
Digital radio is the transmission and reception of sound that has been processed into patterns of
numbers, or "digits."
Channel
A single frequency (or frequency pair: one to transmit and one to receive) dedicated to a single
group or purpose.
Combiner
A device that allows one antenna to be shared by many transmitters.
Console
The dispatch position that allows the dispatcher to access the radio system.

Duplex
The ability to transmit and receive simultaneously.
Simplex
Typical push-to-talk operation or sending and receiving on the same frequency.
Megahertz (MHz)
The unit of measurement of the frequency of radio waves in millions of cycles per second.
Microwave
A transmitter-receiver combination is operating above 2000 MHz.
Trunking
Technology that allows many users to share multiple frequencies on the same radio system
without interfering with each other.
Talkgroup
The trunking equivalent of a channel.
UHF
The part of the radio spectrum from 300-3000 MHz.
VHF
The part of the radio spectrum from 30-300 MHz.
Range
Range (or the distance you can transmit and receive) is determined by several variables,
including power, the height of the antenna, the effects of the atmosphere, trees, buildings, hills
and all other environmental conditions in the area of use.
Portable radios, both VHF and UHF, are essentially straight-line communications devices. VHF
has better penetrating capabilities and can travel farther than UHF.
Things to consider:
Ask your agency’s radio engineer or technician what range you can expect from your radio
model, system and your service area.
Ask about any known “dead” zones.

Are mobile repeaters installed in any of your vehicles or your local fire department or police
vehicles?
Know your radio. Practice with all the buttons and knobs with your gloves on, so you know how
to key it by touch.
Equipment Maintenance
Communications equipment needs to be checked periodically by a qualified technician, to

confirm that it is operating properly. Radios should be checked regularly to verify that they’re not
drifting from assigned frequencies. This will ensure that the equipment is in good working order
when it’s needed.
Portable radio batteries need to be fully charged at the start of every shift, and backups should
be available. Follow the manufacturer’s recommendations for charging your radio’s batteries.
Label the batteries and keep a log to track each battery’s life cycle. Replace a battery when it no
longer holds a charge for the recommended length of time.7
Unfortunately, your equipment might fail in the field despite regular maintenance. Because you
may need to consult online medical direction, an EMS system must provide a backup. Some
agencies issue mobile phones to their EMS providers.
We’ve been talking about the importance of performing equipment maintenance on your
communication devices, but let’s consider what to do if it fails. Take a moment to answer the
following questions:
Do you know what to do if your radio fails?
Do you know who to contact about the radio and where to take it?
What is your agency’s communications backup?
Do you have mobile data computers or terminals installed in the ambulance?
Radio Communications
Communicating With Dispatch
Radio communications keep you connected with dispatch, medical direction, and the receiving
facility. These communications will ensure that the appropriate resources are available to
support you and the patients that you treat.
Each state has its own federally required EMS Communications Plan. Looking at one such
example, in the response phase, New Jersey’s statewide EMS Communications Plan states:

“Field units utilizing radios will advise the dispatch center as they begin their response, arrive at
the scene, begin transport to an acute care facility, [on] arrival at the acute care facility, and as
necessary, or [to] request additional assistance, on their assigned frequency.”6 5
In general, when responding to a call, you need to notify the dispatcher that the call was
received and that the unit is en route. In most systems, this is accomplished through the MCT or
mobile computer terminal. On the screen is a radio button that signifies when the unit is
responding. Other agencies also should be notified, as appropriate (e.g., local hospital). It is
important to note that when you have indicated that the unit is responding, the apparatus should
be rolling or imminently doing so. Automatic Vehicle Locators or AVLs track the movement of
fire rescue and EMS vehicles. They timestamp vehicle speeds during both the response and
arrival phases, among many other data points. If a crew member is delayed getting into the unit,
the best practice is to notify dispatch over the radio of this delay.
An example might be along these lines, “Rescue-57-Dispatch, we have a short delay, a crew
member was in the shower, estimate to be rolling in about thirty seconds.” Your agency may
have a protocol for such an event for you to follow.
A hallmark of good communications is honesty and transparency. By “fudging” the numbers to

make it appear that the unit is en route when it really doesn't show up to a reviewer in prolonged
response times and an AVL query that points to the unit being static at the station or post.
Notify the dispatcher upon arrival on the scene and again when the unit leaves the scene. The
same honesty and transparency rules apply here and, in all aspects, and phases of our
communications.
Whether through MCT or radio, arrival at the emergency department is an important milestone.
Upon your arrival at the hospital or rendezvous point advise dispatch.
Don’t forget to notify the dispatcher when leaving the hospital or rendezvous point and when
you’re ready to go back in service after patient transfer.
Guidelines for Effective Radio Communication
EMS personnel provide information that allows hospitals to prepare for a patient’s arrival by
having the right room, equipment, and personnel prepared.
Follow your agency’s guidelines and format for reporting information. In general, these radio
reports should give the receiving facility enough information to form an acuity impression, make
any internal adjustments, alerts, and get your patient the fastest appropriate level of care.
Because of concerns about interoperability, the general guidelines are to use a plain speech on
the radio — no “10 codes.” You want to be understood by those you’re talking to. If you cannot
be understood, then communication has failed.

The optimal position for transmitting via portable radio is with the handheld unit at head height
and the antenna in a vertical position, says Robert Avsec, a retired battalion chief and former
EMS trainer. He also recommends keeping lips 1 or 2 inches from the microphone.
Before you speak: Think about what information needs to be communicated and put the
information in a standardized format. Pre-thinking the radio transmission will greatly help
streamline and make it more concise for the target audience. Next, ensure that the radio is on
and the volume is properly adjusted. Make sure the channel is clear. Press the push-to-talk
button and wait for a second for the frequency/talkgroup to become yours.
“When speaking into a microphone use a clear and controlled voice that has good resonance
but avoids shouting,” Avsec said.
“When excited, our speech is often both louder and faster. When this happens, our radio
transmissions can be unintelligible and may require the [Incident Commander or dispatcher] to
ask for a rebroadcast, and thus more radio traffic on the channel. If your intended receiver is
consistently asking you to repeat radio communication, you probably need to work on this.”
Be orderly and concise in your presentation. Keep your transmissions brief (less than 30
seconds, if possible, and no more than 60 seconds). Don’t forget that you share the channel.
You aren’t on your personal cell phone. If, on occasion, a transmission takes longer than 30
seconds, stop at that point and pause for a few seconds so other emergency traffic can use the
frequency if necessary.
Courtesy is assumed, so there’s no need to say “please,” “thank you” and “you’re welcome.” But
don’t use profanity on the air. The FCC takes a dim view of such language and may impose
substantial fines on your agency. Just as courtesy is assumed, so to is professionalism. Making
jokes, mocking colleagues, or showing your frustration through your voice is unacceptable.
Omit no important details, but avoid irrelevant details.8 Be accurate, honest and objective. Avoid
speculation and “diagnosing” the patient. Avoid meaningless phrases, such as “Be advised ...”
Patient privacy is important; HIPAA regulations govern our actions during radio transmissions,
as well. Using the name of a patient over the air is not the best practice. In these rare instances
where this type of information needs to be conveyed, it may be wise to do so through the MCT
or via cellular phone directly to the dispatch center. Again, don’t forget that the airwaves are
public, and online scanners are incredibly efficient, very popular and very accessible to the
general public. EMS transmissions may be heard by more than just the EMS community. Use
EMS frequencies only for EMS communications.
Case Study - Communications Breakdowns Make Bad Situations Worse
There are many areas where communication breakdowns can occur and make a bad situation
worse when it comes to 911 calls. If you subscribe to any fire rescue or EMS online newsletters,

then you know that communications failures happen with some degree of frequency across the
nation. Let’s look at a few such situations.
In many of the nearly 5,800 (911) systems across the country, the emergency call comes in
through the public safety access point or PSAP. Often times; this is a law enforcement agency
dispatcher. They are trained to discern if the call nature is police, fire, or EMS. For various
reasons that can run the range from a dropped call to ineffective communications, calls have
been misclassified, usually as law enforcement in nature, when they are a medical emergency
or a fire in reality. Nonetheless, delays in dispatching the appropriate units often lead to public
discussions, media attention, and even litigation.
Here is another example. A call comes in for chest pain on a 41-year old male at 0400 hours.
The assigned ambulance indicates that they are responding through their MCT. Both crew
members need to use the restroom, however, and hurry to do so quickly. Once on the road for
what should be a seven-minute response, they make a wrong turn that costs them three
minutes to recover from. In all, including the toilet break, this response in the early morning
hours took fourteen minutes. The patient was experiencing a heart attack, and his estate
litigated the matter. One of the discovery points was the deceptive enroute time and the delayed
response. In court, or anywhere for that matter, once your credibility is shown to be lacking, or
its shown that you lied, it begs the question, where else do you lie or behave deceptively?
In another communications failure, an EMS crew responded to a call for a severe difficulty
breathing. The patient was very critical and required advanced airway management. The cause
for the patient's condition was correlated to the fact she was also experiencing a heart attack.
The crew raced to get the patient to the ambulance and on her way to the emergency
department. They were driven into the hospital by a firefighter from the local fire department.
The EMS crew thought that the firefighter would call the hospital and vice versa. The end result
was that the hospital was not pre-alerted to the incoming STEMI and the cath-lab team was
delayed by forty minutes in time is muscle situation.
In the early hours of a Saturday morning, police, fire, and EMS response to a “man down” call.
Enroute there is an update through the MCT that “the man may be dead.” The caller stated this,
and the dispatcher entered it in verbatim. The EMS crew slowed down to non-emergency
leaving the first responders from fire and police to handle the patient who was very much alive
and suffering from a stroke. Simple utterances or key strokes can have profound effects and
consequences. Think before you speak or enter any information into the MCT.

Communication En Route
Medical Direction
In some systems, medical direction is at the receiving facility. In others, medical direction is at a
separate site. In either case, EMS personnel may need to contact medical direction for
consultation and to get orders for administration of medications.
Radio transmissions need to be organized, concise and pertinent.
Because the physician will determine whether to order medications and procedures based on
the information given by the EMS provider, this information must be accurate. After receiving an
order for a medication or procedure (or denial of such a request), repeat the order back word for
word. Orders that are unclear or that appear to be inappropriate should be questioned or
clarified for the provider.
Tip: Observe physicians and nurses in the emergency department as they receive EMS radio
reports. Note their attention span.
When communicating with medical direction or the receiving facility, a verbal report should be
given. David Gurchiek, MS, NREMT-P, suggests a SOPE-Q format:8
S – subjective (i.e., What happened before your arrival?)
O – objective (i.e., What did you find on arrival?)
P – plan (i.e., treatment/intervention)
E – evaluate (i.e., patient condition after treatment)
Q – questions (i.e., physician questions, suggestions, orders)
Remember: be clear and concise.
The North Central Regional Trauma Advisory Council (NCRTAC) in Wisconsin offers the
following tips on how to give your patient report:9 Begin with identifiers, your name, the agency’s
name, and your unit number. Then, move on to the following:
Patient Info
● patient’s age
● chief complaint
● associated symptoms (if pertinent)

● history of this illness/injury
● pertinent past history
● medications (only if it is pertinent)
Physical Exam Findings
● environment (if pertinent)
● presentation/appearance
● level of consciousness (LOC) & ABCs
● pertinent findings/injuries
● vital signs
● electrocardiogram (ECG) & 12-lead ECG (if pertinent)
● glucose (if pertinent)
● thrombo inclusions/exclusions (if pertinent)
Interventions/Treatment (Plan)
● oxygen/bag-valve mask/endotracheal tube
● CPR/defibrillation/sync Cardioversion
● medications (dose/route)
● spinal motion restriction (SMR)
Other
● ETA
● orders requested
● any questions or further orders?
● sign off
After giving this information, the provider will continue to assess the patient. Additional vital
signs may be taken, and new information may become available, particularly on long transports.
In some systems, this information should be relayed to the hospital. Refer to your local protocol
for guidance on this issue. Information that must be transmitted includes a deterioration in the
patient’s condition.

The Patient Hand-off

Verbal Report to Hospital Staff
Obtaining the necessary information during patient interaction is key to a successful patient
hand-off later.11 Strong verbal communication skills will ensure that you obtain pertinent
information from the patient and that the receiving facility has the information it needs to provide
high-quality care to the patients you transport.
After arrival at the hospital, you will give a verbal report to the staff. Start by introducing the
patient by name, if the name is known. Then summarize the information you gave over the
radio, including the chief complaint. Report any additional treatment given and additional vital
signs taken en route.
Don’t forget to report any pertinent history that was not given previously. Provide any additional
information that was collected but not transmitted previously.
There’s no need for a lengthy hand-off. Keep it brief, relevant, and concise.
Two mnemonics can help you in your hand-off: SBAT (Situation/Scene, Background,
Assessment, and Treatment) and MIVT (Mechanism, Injuries, Vitals, and Treatment).
Patient Handoff – SBAT
To Learn more about the patient handoff mnemonic term SBAT (Situation/Scene, Background,
Assessment, and Treatment), click each term below.
Situation/Scene
After you state your unit designation, name, and certification level, give a brief but thorough
description of the scene or incident. Then give the patient’s gender, age, and chief complaint.
Background
Give the history of present illness or information on the background of what happened to the
patient. Provide more in-depth, precise information that you gave over the radio. Also include
relevant medical history, medications, and allergies. Report only pertinent information.
Assessment
Provide pertinent assessment findings, including a general impression of the patient. Include
stable versus unstable observations, as well as ECG findings, blood glucose levels, and a
stroke scale, if relevant. You’ll also want to include baseline vital signs and pain level rating, if
applicable.
Treatment

Explain what treatment was given. Include the patient’s response. This is the time to restate
concerns about the patient and to respond to questions.
The second mnemonic is specific to trauma patients.
Patient Handoff – MIVT
To Learn more about the patient handoff mnemonic term MIVT (Mechanism, Injuries, Vitals,
Treatment), click each term below.
Mechanism
Describe the mechanism of injury related to the traumatic event or injury. Include such specifics
as the height of fall, speed of the vehicle, and information on any other blunt or penetrating
mechanisms.
Injuries
Indicate obvious and suspected injuries. Also, include a patient’s complaint in this section.
Vitals
Give a thorough and complete set of vital signs, including Glasgow Coma Scale score, pupillary
response and any significant changes in the vitals throughout the patient contact time.
Treatment
Explain treatments administered and the patient’s response to the treatment. Also, include any
significant changes to the patient’s condition.
Interpersonal Communication
Interpersonal Communication Skills
To adequately assess and care for your patients, you must be able to gather information about
the patient’s chief complaint and history. This requires strong interpersonal communication
skills.
Garry Harris, an Australian paramedic, was recently a patient for a proactive health check
requiring day admission. He posted the following advice on his Facebook page specifically to
his fellow caregivers: “Always introduce yourselves to your patient, state your purpose and listen
to a response.”
Harris said that step was neglected by the first two providers to interact with him. “It was the
third person, in pre-med, who was addressing me with questions which finally introduced
himself and actually engaged with me as a human,” he said. “The rest was like a factory
production run. Once the patient was engaged in a way that made him feel that the caregiver

was in tune with him, he began to feel less unease and more comfortable. Humanism makes all
the difference at the bedside or on a scene call.
His takeaway: “I am going to try harder to engage better with those trusting their time with me
as a healthcare professional.”
Act and speak in a calm, confident manner. The following tips can help you communicate
effectively with your patients:12
Listen more; talk less
Ask open-ended questions. Allow the patient enough time to answer a question before asking
the next one. Pay attention to verbal and nonverbal cues. Ask for clarification if you don’t
understand something.
Build rapport
Use the patient’s proper name, either first or last, depending on the circumstances. When
possible, ask the patient what they’d like to be called. Be sensitive to the patient’s beliefs, fears,
and social and cultural background. Encourage them to ask questions. Show interest in their
concerns.
Communicate in plain English
Speak slowly, deliberately and clearly. Provide information in small chunks, and don’t
overwhelm patients with technical details or jargon. Where appropriate, use pictures or
diagrams. If a patient has difficulty hearing, speak clearly with lips visible.
Use appropriate body language and voice tone.
Remember, your body language speaks to the patient as well. Make and maintain eye contact,
and remain attentive. Speak in a firm yet friendly tone.
Be accurate and truthful
Explain what you’re doing. Make sure your message is clear and understood. Ask the patient to
repeat instructions.
Pre-Hospital Care Report

Importance of Documentation
Documentation is a key element in the continuum of patient care. The EMS provider must
document what the patient complained of, what care was provided, as well as any treatment(s)
that was withheld, perhaps due to contraindications or refused by the patient. A prehospital care

report (PCR) is the form used to document emergency care and must be filled out for every
patient encounter.
The primary purpose of the PCR is to document all care and pertinent patient information, and
to serve as a data collection tool. A PCR must be filled out for every patient encounter and
serves a variety of functions.
A PCR must be completed anytime that patient contact is made, when patients are transported
to any location; when patients refuse care and/or transport; when patients are treated by one
agency and transported by another; and for calls on which no patient contact is made, such as
for calls canceled before reaching the scene, for calls where no patient is located, and when
dispatched for a standby. If an agency is dispatched to a standby and, while there, they treat a
patient, two PCRs should be completed: one as a record of the event and one for the patient
care provided.
The PCR (including a first responder report) serves as a patient care record. The patient care
record documents the patient’s condition at various points in time and the interventions
provided, and it provides for continuity of care at the receiving hospital for the health care
providers who take over patient care. Even a form that is not read immediately in the emergency
department may be referred to later for important information.
The medical encounter often has several different areas of data that it captures:
● Patient centric information used for billing (DOB, SSN, address, etc.),
● Your charting to support the care given, the billing (Assessments, treatments,
procedures, and charting treatment outcomes).
● State and federal data elements (registries and National EMS Information System
(NEMSIS) data elements.
The PCR should not be started at the scene if filling it out would compromise or delay patient
care. However, when there is sufficient personnel on the scene, it is not uncommon to assign
one person as a scribe. This team member is assigned to obtaining pertinent patient information
and demographics. This part of the patient report is often done on an abbreviated paper report.
If sufficient staff are not on the scene, never delay patient care to work on the PCR.
Regardless, the PCR should be completed promptly after patient contact. A delay could mean
you forget important observations or treatments. If possible, a copy of the completed report
should be left with the emergency department staff before you leave the receiving hospital, in
accordance with your agency policies.
Legal Document
The PCR serves as a legal document in the case of any legal action. It may be reviewed
internally, as well as externally. If litigation ever arises, what you stated in the report, or didn’t
state may come into play. A good report documents what emergency medical care was

provided, the status of the patient on arrival at the scene, and any changes on arrival at the
receiving facility. The person who completed the form ordinarily must go to court with the form.
The forms should include objective and subjective information and be clear. The PCR will
document that the care you provided was appropriate.
Imagine this very basic scenario between a lawyer and EMT during a trial:
Lawyer: “He had full movement before you touched him, and now he is paralyzed.”
EMT: “No, sir, he had no feeling and couldn’t move when we first checked him out.”
Lawyer: “Per your report, Mr. EMT, your only mention of neurological status was during your
secondary survey after you removed him from the car, so I say you caused his
disability.”
The takeaway is if you didn’t write it down, it didn’t happen. Documenting everything you do can
protect you, your patients, your agency, and the profession. Good documentation can help
reduce complaints against the department and the risk of litigation. This, in turn, reduces the
overall risk to the agency and ensures that the community continues to respect the profession.
Important note
No EMS provider or agency is obligated to provide a copy of the PCR simply at the request of a
law enforcement officer or other agency. If a copy of the PCR is being requested as part of an
official investigation, the requestor must produce either a subpoena, from a court having
competent jurisdiction or a signed release from the patient.
Good EMS documentation should create a picture so the person reading the report can
visualize that patient's condition, according to lawyers and nationally known EMS consultants
Douglas Wolfberg, JD, EMT-P, and Steve Wirth, Esq., EMT-P.
Quality Improvement Instrument
The PCR can also serve as a quality improvement instrument. For instance, the agency’s
medical director can conduct spot checks of PCRs to ensure that protocols were followed, use
the PCR to demonstrate proper documentation, and pull extract lessons learned on how to
handle unusual or uncommon cases for future in-service training or corrective action.
Research
Under the Health Insurance Portability and Accountability Act (HIPAA), data collected from
PCRs can be used for research purposes to help an agency analyze common types and causes
of injuries to identify better methods of care, necessary changes to protocols, and any potential
problems. And finally, as an administrative document the PCR is used as a billing resource.

Paperless Reporting or ePCRs
Practically speaking, the profession made the jump to electronic, paperless, reporting many
years ago. Functionally speaking, this does not mean that the process is entirely without paper
in every organization. Even with electronic patient care records or ePCRs, it is often necessary
to leave the hospital or receiving entity with an abbreviated paper report that lists the basics of
the call and the care that was provided by you.
From a quality assurance aspect, ePCRs can allow a reviewer to extract or liberate data
elements that they are interested in. For instance, what percentage of IV attempts were
successful, how often advanced procedures occur in a given daypart, or the outcomes from
critical events, such as cardiac arrest or stroke. Easy access to these data elements is a query
away and can serve an agency well.
EMS departments are experiencing an increasing need for greater implementation of

technology in their reporting systems. The shift to paperless reporting, with information stored
on a database, now allows for timely retrieval of patient information, that was never before
possible. It also helps in monitoring EMS care and injury trends and helps ensure appropriate
staffing levels, because it’s easier to view the number of runs at certain locations and times.
Increasingly third-party quality assurance tools or programs can look for defined outliers in care
and generate exception reports that deliver actionable daily, even real-time QA intelligence to a
quality assurance officer when a call doesn’t go according to the medical protocol parameters.
The PCR Form

You may encounter a variety of PCR forms. Some systems may still use a traditional written
form with check boxes and a narrative section, but most will use a computerized version in
which information is filled in using a PDA, tablet, ruggedized laptop or a similar device.
Regardless of the type, the PCR generally contains the following sections:
Run Data Patient Data
● date ● name ● location of patient
● times ● address ● the treatment administered before

the arrival of EMS provider
● service ● date of birth
● signs and symptoms
● unit ● sex
● care administered

● shift ● age ● baseline vital signs
● names of ● social security ● SAMPLE history

crew number
● any changes in condition
● insurance
information ● agency or state-specific registries
or alerts
● nature of call
● mechanism of
injury
Document Basic Patient Information
At a minimum, you must document basic patient demographic information, medications,

allergies, the event/incident, assessment findings and treatment details, and all other required
fields specified by individual departments.
Ensure that your documentation is truthful, accurate, objective, pertinent, legible, and complete.
Use proper spelling and grammar and appropriate abbreviations.
Include your name and unit information, and the information you received from dispatch. Record
the patient’s name, address, and other contact information.
Narrative Section Tips
The PCR should record 14 the patient’s chief complaint and a complete history or sequence of
events that led to their current request or need for care.
It should detail your assessment of the nature of the patient’s complaints and the rationale for
that assessment.
Document your initial physical findings, a complete set of initial vital signs, and all details of
abnormal findings considered.
It is important to provide an accurate assessment and significant changes important to patient

care. Reflect ongoing monitoring of abnormal findings both in the narrative and also within the
flow sheet following given procedures or treatments.
Summarize all assessments, interventions and the results of the interventions with appropriate
detail so the reader can fully understand and visually recreate the events.

Include an explanation for why an intuitively indicated and appropriate assessment, intervention,
or action that is part of your agency’s protocols and clinical guidelines did NOT occur.
Clearly, describe the circumstances and findings associated with any complex call or
out-of-the-ordinary situations.
Many experts recommend using the SOAP (i.e., subjective, objective, assessment, plan) format
to complete the narrative section of the PCR.14 Meanwhile; there are others who advocate for
the CHART method. CHART stands for Complaint, History, Assessment, Rx (prescribed)
medications, and Treatments.
Then there are those who use variants of each or another methodology altogether. If your
agency requires one specific format, obviously use it. If they do not, both SOAP and CHART are
excellent means by which to establish your mental template for report crafting that will be called
upon at all hours of the day with varying levels of fatigue.
Patient Confidentiality
The form itself and the information on the form are considered confidential and protected under
HIPAA. Be familiar with all of the varied federal and state laws regarding the release of
confidential patient information. Distribution of the PCR will be guided by state and local
protocols.
ePCR Errors
In the case of ePCRs, these systems often have a means by which a reviewer can view all
changes over time and by whom. This can mean that if you modify a report several times during
a shift prior to submission, all of the iterations may be viewable, if needed.
As a report writer, it can be beneficial to sketch out timelines from the scribe's notes on the
scene or from cardiac monitor summaries and the like before committing to entering these
findings into the ePCR.
In the case of medical errors, these may include the wrong drug, dosage, route, treatment,
procedure among the long list. They can be errors of omission or commission. If an error or
medical mistake occurs, it is imperative to notify your medical control and the receiving facility,
as well. Medical mistakes do unfortunately occur from time to time. In the best interest of the
patient, the standard of care is to make them immediately known and part of the report.
Falsification Issues
Never record false information or exaggerate. Falsification of information on the PCR results in
poor patient care because other health care providers will have an inaccurate impression of
what findings were discovered by assessment. Falsification can be uncovered by experienced

reviewers. Falsifying information within an official report can come with administrative, civil, and
even criminal penalties in some instances.
When an error of omission or commission occurs, don’t try to cover it up. Instead, document
what did or did not happen and what steps were taken, if any, to correct the situation.
A couple of areas commonly cause problems:
Vital signs
Document only the vital signs that were actually taken.
Treatment
If a treatment such as the administering of oxygen was overlooked, do not report that the patient
was given oxygen.
Patient Signatures
Patient signatures are required for billing purposes, especially for Medicare and Medicaid. In
cases where the patient cannot sign, when a patient is unconscious, doesn’t have use of their
hands, or has altered mentation, as examples, the receiving facility may sign for the patient.
Often this is the receiving nurse or physician.
When this occurs, most ePCR programs require an additional attestation by one or both crew
members that a condition prohibited the patient from signing the patient responsibility section.
Investigators can query the electronic signatures during routine audits of any agency that
accepts either Medicare or Medicaid. Inconsistencies, shortcomings, even fraud is discovered
during these audits. The result of which can be fines, loss of funding, and even federal criminal
charges. Always follow best practices and obtain clear, concise signatures per your agencies
policies, and both state and federal laws.
EMS agencies may impose sanctions, including suspending an EMS provider for falsifying
information on the PCR. Falsifying information may lead to the suspension or revocation of the
EMS provider’s certification/license, as well as fines levied by the state body that regulates EMS
providers of care.15, 16
Consent & Refusal

Types of Consent
By law, you must obtain a patient’s consent before you can provide medical care or transport.17

When a patient directly grants permission to treat (whether verbally, nonverbally or in writing), it
is considered expressed consent.
In the case of a minor or a mentally incompetent adult, consent should be obtained from a
parent, legal guardian, or court-appointed custodian. If a responsible adult cannot be found, the
patient may be treated under the doctrine of implied consent. It is assumed they would want
lifesaving treatment if they were able to give informed consent. Unconscious patients can’t grant
consent, so their treatment also depends on implied consent.
Involuntary consent occurs when a court orders a patient to undergo treatment.
Types of Refusals
Competent adult patients and emancipated minors have the right to refuse treatment.4, 17
However, minors cannot refuse care unless they are emancipated. Emancipation laws vary by
state but generally come with a court order proclaiming that a minor is emancipated and may
function as an adult or occurs under certain specific circumstances, such as when a minor is
pregnant and/or gives birth. The emancipation is often limited in these circumstances to specific
instances such as approving or refusing care for their child (born or unborn). In all instances, the
refusal of care must be informed. This means that the refusal must be explained to the patient,
including any and all consequences to the refusal, up to and including death. For a patient to be
fully informed, they must be completely lucid and competent to make such a decision. Patients
under the influence of intoxicating drugs, alcohol, or those who are hypoxic or hypoglycemic, as
a few examples, are likely not competent. A patient who is suicidal or whose judgment is
impaired because of drugs or alcohol, as examples, can be transported even if they refuse
because of their inability to legally provide informed consent. When handling a patient refusal,
be sure to document everything.
Before you leave the scene, however, if the patient needs immediate attention, you should:
● Ensure that the patient is able to make a rational, informed decision.
● Try again (multiple times) to persuade the patient to go to a hospital.
● Inform the patient why they should go and what may happen to them if they don’t.
● Consult medical direction as directed by local protocol.
● If the patient still refuses, document any assessment findings and emergency medical
care given, then have the patient sign a refusal form.
● Have a family member, police officer or bystander sign the form as a witness. If the
patient refuses to sign the refusal form, have a family member, police officer or
bystander sign the form verifying that the patient refused to sign.
● Offer alternative methods of gaining care.

● State your willingness to return if needed.
● Complete the PCR.
Document the care you wished to provide for the patient, including a statement that you
explained to the patient the possible consequences of failure to accept care, including potential
death.
In the event of patient refusal, all additional responding medical personnel should be cancelled.4
Special Situations and Considerations

Social Media
Any course or lesson on communications would be remiss if it didn’t discuss social media.
Currently, the most popular current social media landscape includes Facebook, Twitter,
Instagram, LinkedIn, Reddit, and Snapchat.
Once upon a time, in most circles, social media meant the website MySpace. That was then;
this is now. In due time, whatever that is in today's rapidly changing cyber world, the social
media of today will also be replaced by others, and these current stalwarts may also come to be
unknown at that point. However, the posts on these platforms will likely live on forever on the
Internet.
The social media platform notwithstanding, they exist and profit through your personal data in
the way of posts. These posts are a form of communication.
As first responders, we are often tempted to discuss aspects of what we do on social media
sites. There is no shortage of guidance on this topic online, in academia, and elsewhere. Where
this course will offer guidance on this subject is this.
On any given week, the EMS and fire rescue news blogs often report on firefighters, EMTs, and
paramedics who have been suspended or fired for their social media posts. If you directly or
indirectly mention a patient, your agency, an event involving a patient, victim or your agency you
are crossing a line of professional, legal, and ethical acceptance that puts all that you value at
risk.
Posting about a call that you ran, showing pictures of the call, detailing aspects of what
happened and where it occurred can all become problematic for you a rescuer. You may be
violating federal or state HIPAA laws or you may be infringing upon your department's policies
on these subjects. The best advice that can be given to you is to not post anything related to
any calls for emergency service. Period.

Events
Many agencies work large scale events from time to time. A large-scale event may be one that
has thousands, or even hundreds of thousands of attendees. These include football games,
fairs, concerts, convention, and more. Your agency will have a documentation policy for when
these occur. No matter how brief the patient encounter, basic demographics, as well as a
summary of the treatments received should be charted.
Multiple Casualty Incidents (MCI)
When caring for multiple casualties, there may not be enough time to complete the PCR before
responding to the next call. When this is the case, you will need to fill out the report form later.
Your local Multiple Casualty Incident (MCI plan) should have some means of recording
important medical information temporarily (e.g., triage tag) that can be used later to complete
the form. Follow your local protocols for completing the PCR.
While emphasizing that transport should not be delayed to fill out the triage tag, the
Multi-Casualty Incident Response Plan for San Mateo County in California calls for triage tags to
be used on each patient during an MCI, documenting at minimum the chief complaint/injury(ies),
field treatment, the triage tag number, vital signs (if possible) and the patient name (if
possible).18
San Mateo also requires a PCR to be completed by the transporting EMS crew for all MCI
patients transported by ambulance.
Special Situation Reports
Special situation reports are used to document events that should be reported to local
authorities, such as exposure to bloodborne pathogens or on-the-job injuries.17 These reports
should be submitted promptly and should be accurate and objective. You should submit the
report to the authority described by local protocol and keep a copy for your own records.
The federal Centers for Medicare & Medicaid Services (CMS) requires a certificate of medical
necessity for non-emergency transports from skilled nursing facilities.19
Conclusion
Final Thoughts
The best patient care may come to an end at the door of the emergency department if a
patient’s condition is not described well enough for the ED staff to prepare. To establish the
continuum of care, the EMS provider must document not only what the patient complained of,

but also what they denied. A prehospital care report must be filled out for every patient
encounter.
A PCR must document the nature and extent of emergency medical care. Documentation is an
ongoing process, and the report provides information that can be used in many constructive
ways. Well-prepared reports are important medical/legal documents. If it is not written down, it
was not done, and if it was not done, do not write it down.
Health care providers use the information from the report to monitor changes in patient
condition. In particular, the trending of mental status and vital signs is extremely important to
physicians and nurses who assume care. The information on the report can also be used in the
quality assessment of emergency medical care.
Communications is at the heart of the EMS, fire rescue, and public safety business models.
From the start of the 9-1-1 until the patient is handed off and the ePCR completed, we are
constantly communicating.
Summary (summary.cfm)
Congratulations!
You have completed the learning portion of this course. Several key points were covered on the
importance of communication skills. Before moving onto the final exam, take a moment to
refresh yourself on the terms used throughout the course. If any of the terms seem unfamiliar,
click on the Table of Contents, located in the blue sidebar, to go back and reread the
corresponding lessons before taking the test.
To maximize your retention and better assure the successful completion of this offering,
consider the following:
Throughout this course, each lesson concludes with multiple study questions that will ultimately
prepare you, the learner, for the comprehensive final exam that must be passed in order to be
awarded a continuing education unit(s).
Learners should familiarize themselves with key terms found within the glossary.
Before beginning the final exam at the course end, there will also be a study exercise that
correlates with these important subject related terms and vocabulary. By comprehending the
subject related terms and vocabulary and passing this knowledge review, the concepts will be
better cemented, and your newly acquired knowledge can then be effectively applied within your
professional best practices, and lastly assist you with the final exam questions.

References
1. APCO International. Minimum Training Standards for Public Safety Telecommunicators.

APCO ANS 3.103.1-2010.
2. The National 911 Program. 911.gov.
3. Emergency Communications. Federal Communications Commission. FCC.gov.
4. Santa Clara County (Calif.) Emergency Medical Services. Emergency Medical Services
Agency Prehospital Care Manual, Policy 500: Prehospital Care Patient Documentation.
Effective date: Jan. 22, 2007.
www.sccgov.org/sites/ems/Documents/pcm500/0-500-Prehospital-Patient-Care-Docume
ntation-012207.pdf.
5. Your secret decoder ring: A guide to the understanding of geeks. Public Safety
Communications. June 2007; 73(6):64.
6. State of New Jersey Department of Health and Senior Services Office of Emergency
Medical Services. EMS Communications Plan. JEMS – 4th edition. Created January
1980; revised October 2003; and revised July 2006.
7. Avsec R. 4 skills for better radio communication. FireRescue1.com. Oct. 16, 2012.
8. Gurchiek D. Talk radio: The art of verbalizing visual images. JEMS. March
2001;26(3):88–98.
9. North Central Regional Trauma Advisory Council (NCRTAC). Tips for radio reporting &
example format. EMS Professions at Temple College.
ncrtac-wi.org/uploads/Radio_Report_tip.pdf.
10. Liebelson D. 8 cities where 911 systems recently failed. Mother Jones. Aug. 5, 2013.
www.motherjones.com/politics/2013/07/911-dispatch-emergency-system-fail-breakdown
11. Wurster FW. Mnemonic device helps patient hand-offs. jems.com. July 1, 2011.
m.jems.com/article/training/mnemonic-device-helps-patient-hand-offs
12. Maryland Health Care Commission. Tips for talking with your patients. July 3, 2012.
184.80.193.37/consumerinfo/hospitalguide/practitioners/practitioner_help/tips_for_talking_
with_your_patients.htm.
13. New York State Department of Health. Prehospital Care Reports. Jan. 23, 2012.
www.health.ny.gov/professionals/ems/policy/12-02.htm.
14. Pre-hospital clinical documentation. City of Corvallis, Ore.
https://www.corvallisoregon.gov/modules/showdocument.aspx?documentid=4602.
15. The Pennsylvania Code. www.pacode.com/secure/data/028/chapter1031/s1031.3.html.

16. Virginia.
oems-notes.vdh.virginia.gov/compIntr.nsf/0136157484aeb31985256bb5006d3e5b/595e643
c14432ff185257b9c005dc4da?OpenDocument.
17. Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care, 2nd edition, update.
Brady, an imprint of Pearson Education Inc., Upper Saddle River, N.J. 2011.
18. County of San Mateo (Calif.) Multi-Casualty Incident Response Plan. Issue date: May 1,
2003; Effective date: November 22, 2011; Review date: July 2012.
www.smchealth.org/sites/default/files/docs/EMS/Operations9_MCI_Nov_2011.pdf.
19. Buncombe County (North Carolina) EMS.
http://emsstaff.buncombecounty.org/inhousetraining/Documentation/default.asp.
Resources
References
Subject Matter Expert

Paul Costello

EMS Communication and Documentation

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EMS Communication and Documentation

EMS Communication and Documentation

The Patient Hand-off 14

Pre-Hospital Care Report 16

The PCR Form 19

Page 2 of 28 © Vector Solutions

Consent & Refusal 22

Special Situations and Considerations 24

Subject Matter Expert 28

Page 3 of 28 © Vector Solutions

After successfully completing this course, you will be able to:

● Describe the elements of a public safety communications system

● Explain the importance of effective communication and documentation of patient

● List the types of patient consent and refusal of care

● Identify the importance of providing accurate documentation (oral and written) in

Page 4 of 28 © Vector Solutions

Page 5 of 28 © Vector Solutions

The handheld unit you carry with you.

A device that allows one antenna to be shared by many transmitters.

Page 6 of 28 © Vector Solutions

The ability to transmit and receive simultaneously.

Typical push-to-talk operation or sending and receiving on the same frequency.

A transmitter-receiver combination is operating above 2000 MHz.

The trunking equivalent of a channel.

The part of the radio spectrum from 300-3000 MHz.

The part of the radio spectrum from 30-300 MHz.

Ask about any known “dead” zones.

Page 7 of 28 © Vector Solutions

Communications equipment needs to be checked periodically by a qualified technician, to

Do you know what to do if your radio fails?

What is your agency’s communications backup?

Do you have mobile data computers or terminals installed in the ambulance?

Page 8 of 28 © Vector Solutions

A hallmark of good communications is honesty and transparency. By “fudging” the numbers to

Guidelines for Effective Radio Communication

Page 9 of 28 © Vector Solutions

Case Study - Communications Breakdowns Make Bad Situations Worse

Page 10 of 28 © Vector Solutions

Page 11 of 28 © Vector Solutions

Radio transmissions need to be organized, concise and pertinent.

S​ – subjective (i.e., What happened before your arrival?)

O​ – objective (i.e., What did you find on arrival?)

P​ – plan (i.e., treatment/intervention)

E​ – evaluate (i.e., patient condition after treatment)

Q​ – questions (i.e., physician questions, suggestions, orders)

Remember: be clear and concise.

● associated symptoms (if pertinent)

Page 12 of 28 © Vector Solutions

● history of this illness/injury

● pertinent past history

● medications (only if it is pertinent)

Physical Exam Findings

● environment (if pertinent)

● level of consciousness (LOC) & ABCs

● electrocardiogram (ECG) & 12-lead ECG (if pertinent)

● glucose (if pertinent)

● thrombo inclusions/exclusions (if pertinent)

● oxygen/bag-valve mask/endotracheal tube

S – subjective (i.e., What happened before your arrival?)

O – objective (i.e., What did you find on arrival?)

P – plan (i.e., treatment/intervention)

E – evaluate (i.e., patient condition after treatment)

Q – questions (i.e., physician questions, suggestions, orders)

Involuntary consent occurs when a court orders a patient to undergo treatment.