Better documentation

PCR phrases to avoid

Replace vague labels with observable findings, measured data and clinically useful detail.

50 phrases

Patient stable

Document the actual findings and trend: e.g., HR 84, BP 128/76, RR 16 unlaboured, SpO2 97% RA, GCS 15; no significant change during transport.

Avoid

Vitals normal

Write instead

Record the actual vital signs and relevant trend.

Avoid

Vitals stable

Write instead

State the range/trend: e.g., serial BP 118-126 systolic with HR 72-80.

Avoid

Patient fine

Write instead

Describe appearance, symptoms, function and vital signs.

Avoid

No issues

Write instead

State what was assessed and what was not found.

Avoid

No complaints

Write instead

Specify relevant negatives: e.g., denies pain, dyspnea, dizziness, nausea or weakness.

Avoid

No distress

Write instead

Describe respiratory effort, speech, posture and vital signs.

Avoid

NAD / no acute distress

Write instead

Replace the label with the objective findings supporting it.

Avoid

Neuro intact

Write instead

Document GCS, speech, facial symmetry, strength/drift, sensation and gait as relevant.

Avoid

CMS intact

Write instead

Document distal pulse/circulation, sensation and movement separately.

Avoid

Good CMS

Write instead

Describe each neurovascular component.

Avoid

Airway patent

Write instead

Describe speech/air movement and absence of obstruction, stridor, gurgling or drooling.

Avoid

Breathing okay

Write instead

Document RR, effort, chest rise, sounds and SpO2.

Avoid

Lungs clear

Write instead

State breath sounds and absence of wheeze/crackles/rhonchi.

Avoid

Good air entry

Write instead

State breath sounds present/equal and where auscultated.

Avoid

Circulation good

Write instead

Describe pulse quality/rhythm, skin, BP and capillary refill when relevant.

Avoid

Perfusion adequate

Write instead

Describe mentation, pulse, skin, BP and capillary refill.

Avoid

Abdomen normal

Write instead

Document soft/firm, distension, tenderness, guarding and other relevant findings.

Avoid

Chest normal

Write instead

Document symmetry, tenderness, crepitus and visible injury.

Avoid

No trauma noted

Write instead

State the areas assessed and the relevant negative findings.

Avoid

No obvious injury

Write instead

Specify what was inspected/palpated and what was found.

Avoid

Patient fell

Write instead

Describe cause/mechanism, height/surface, head strike, LOC and injuries.

Avoid

Mechanical fall

Write instead

Describe why it appears mechanical and pertinent negatives for a medical cause.

Avoid

Possible LOC

Write instead

State witness report, patient recall and estimated duration.

Avoid

Unknown LOC

Write instead

Explain why LOC cannot be excluded, e.g., unwitnessed with amnesia.

Avoid

Poor historian

Write instead

Explain why the history is limited: dementia, aphasia, intoxication, language barrier, pain, etc.

Avoid

Unreliable historian

Write instead

Describe inconsistencies and identify collateral sources.

Avoid

Confused

Write instead

Document orientation, behaviour, baseline and specific deficits.

Avoid

Altered

Write instead

Document GCS/AVPU and observable cognitive/behavioural findings.

Avoid

Normal mentation

Write instead

Document orientation and whether behaviour is baseline.

Avoid

Uncooperative

Write instead

Describe the exact behaviour and what assessment/treatment was declined.

Avoid

Difficult patient

Write instead

Describe observable behaviour without judgment.

Avoid

Aggressive

Write instead

Describe threats, posturing, attempts to strike, or other specific actions.

Avoid

Drug seeking

Write instead

Document requests, reported symptoms and objective findings without assigning motive.

Avoid

Intoxicated

Write instead

Document reported substance use and observable findings.

Avoid

ETOH on board

Write instead

Record amount/timing when known plus objective findings.

Avoid

High on drugs

Write instead

Record reported substance, route/time and observable toxidrome/behaviour.

Avoid

Non-compliant

Write instead

Describe what medication/care was not followed and the patient-reported reason.

Avoid

Refused treatment

Write instead

Document what was offered, why it was recommended, capacity/understanding and what was declined.

Avoid

Refused transport

Write instead

Document recommendation, risks/benefits discussed, understanding, capacity and disposition.

Avoid

Patient understands risks

Write instead

State which risks were discussed and how understanding was demonstrated.

Avoid

Tolerated treatment well

Write instead

Describe objective response and absence/presence of adverse effects.

Avoid

Good effect

Write instead

Quantify what changed after treatment.

Avoid

No effect

Write instead

State symptoms/findings before and after, including time interval.

Avoid

Condition improved

Write instead

Specify which symptoms, signs or measurements improved.

Avoid

Condition deteriorated

Write instead

State exactly what changed and when.

Avoid

Transported without incident

Write instead

Document relevant reassessments and whether condition changed.

Avoid

Uneventful transport

Write instead

Record clinically relevant reassessments rather than the label.

Avoid

Report given to nurse

Write instead

Document recipient and key handover elements.

Avoid

Care transferred

Write instead

Document to whom, when, patient condition and transfer circumstances.