EMS Narrative Builder — PCR Template v2

Run Information

Ambo #

Incident #

Patient Age

Gender

Pt (Reported By)

Destination

Dispatch & Chief Complaint

Onset Duration

Time Since Onset (Approx.)

Chief Complaint

Primary Complaint

Severity (1–10)

Describe Chief Complaint

Additional Context (optional)

Neuro / LOC

GCS Total

Alert & Oriented

LOC / Syncope

Physical Exam Findings

Trauma Survey — DCAP-BTLS

DCAP-BTLS Deformity · Contusions · Abrasions · Punctures · Burns · Tenderness · Lacerations · Swelling

Head, Eyes, Ears, Nose, Throat

HEENT Head · Eyes · Ears · Nose · Throat

Abdomen

Abdomen Palpation assessment

RDGTP × 4 Quadrants Rebound · Distension · Guarding · Tenderness · Pulsation

Extremities

Distal PMS × 4 Extremities Pulse · Motor function · Sensation

Pertinent Negatives Green = denied/absent · Red = present

SOBShortness of Breath

LOCLoss of Consciousness

NauseaNausea

VomitingVomiting

HematuriaBlood in Urine

FeverFever / Chills

NVDNausea/Vomiting/Diarrhea

JVDJugular Vein Distension

Vital Signs

Last Time Vitals Taken

BP (sys)

BP (dia)

HR (bpm)

RR (/min)

SpO₂ (%)

SpO₂ Condition

BGL (mg/dL)

Medical History & Treatment

Pertinent Medical History

Specify Medical History

Allergies

NKDA — No Known Drug Allergies

Food Allergies

Other Allergies

Treatment

Treatments Rendered

Describe Treatment

Transport

Transport Mode

Authorization