PCR documentation guide

Write a clearer clinical story

SOAP provides a simple structure for a defensible and clinically useful patient care report.

S
What the patient tells you

Subjective

Chief complaint; onset, duration and progression; OPQRST/SAMPLE; associated symptoms; pertinent negatives; relevant history and medications; source of collateral information.

O
What you find

Objective

General appearance; LOC/GCS; ABC findings; vitals and trends; focused exam; neurologic findings; BGL, temperature, SpO₂ and ETCO₂ when relevant; ECG; trauma findings; treatment response.

A
What you think is happening

Assessment

Primary working impression; relevant differential diagnoses; clinical severity; improving, worsening or unchanged. Avoid claiming certainty beyond your assessment.

P
What you did

Plan

Treatments and doses, routes and times; oxygen or ventilation; IV/IO; splinting; reassessment; response; transport and destination; pre-alert; transfer of care; refusals or deviations with rationale.

The PCR story

Write chronologically

  1. 1Dispatch
  2. 2Scene
  3. 3Chief Complaint
  4. 4History
  5. 5Assessment
  6. 6Treatment
  7. 7Reassessment
  8. 8Transport
  9. 9Transfer of Care
Documentation essentials

Build a useful record

Write chronologically

Even within SOAP, tell a clear story from dispatch through transfer of care.

Document pertinent negatives

Include negatives that influence your assessment or disposition. Avoid long lists of irrelevant negatives.

Show trends, not just numbers

Document the initial finding, intervention, reassessment and response.

Document baseline

For older adults, long-term-care residents and patients with neurologic or cognitive impairment, document baseline cognition, mobility, speech, oxygen needs and usual supports.

Use quotations when exact words matter

Direct quotes are useful for refusals, suicidal or homicidal statements, threats, capacity discussions, unusual statements and important mechanism or history details.

Document the source

Identify whether information comes from family, staff, witnesses, blister packs or other records.

Complete examples

SOAP in practice

Fall

S

82-year-old female reports tripping over the edge of a carpet and falling onto her left side approximately 45 minutes prior to EMS arrival. Denies dizziness, chest pain, palpitations or weakness preceding fall. Denies LOC and head strike. Takes apixaban for atrial fibrillation. Reports 8/10 left hip pain and inability to weight-bear.

O

Patient found supine on floor, alert, GCS 15. Left leg shortened and externally rotated. Tenderness over left hip. No open injury. Distal pedal pulse palpable, sensation intact and able to move toes. No head, cervical spine, chest, abdominal or other extremity injury identified. Initial vital signs stable by measured values.

A

Mechanical ground-level fall with findings suspicious for left proximal femur/hip fracture. No evidence of distal neurovascular compromise.

P

Analgesia administered per applicable guideline with pain improving from 8/10 to 4/10. Patient transferred using appropriate movement device and positioned for comfort. Distal CSM unchanged after movement. Serial vital signs reassessed. Transported to ED and care transferred with verbal report.

Shortness of breath

S

68-year-old male with COPD reports worsening dyspnea over two days with increased productive cough and yellow sputum. Uses 2 L/min home oxygen. Denies chest pain, syncope or hemoptysis.

O

Patient sitting upright in moderate respiratory distress, speaking 3–4 word sentences. RR 30, SpO₂ 84% on usual 2 L/min oxygen, HR 112. Bilateral expiratory wheeze with decreased air entry. Temperature 38.2 C.

A

Acute COPD exacerbation with hypoxemia. Respiratory infection or pneumonia remains a consideration.

P

Oxygen titrated and bronchodilator therapy administered as indicated. Following treatment, SpO₂ improved to 91%, RR decreased to 24 and patient able to speak in longer sentences. Transported to ED with ongoing reassessment.

Before signing

Final PCR check

  • Does the narrative clearly explain why EMS was called?
  • Did I reassess after interventions?
  • Did I establish baseline when relevant?
  • Can the reader tell whether the patient improved, deteriorated or stayed unchanged?
  • Did I document important red flags and pertinent negatives?
  • Did I explain unusual decisions, delays, refusals or deviations?
  • Do the findings support my clinical impression?
  • Is the language factual, objective and respectful?
  • Did I document treatment doses and response?
  • Could another clinician understand the encounter without speaking to me?