Detailed EMS Handover Notes - Prehospital Care Report (PCR)

DISPATCH INFORMATION Date: [insert date of incident] (only include date if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Incident #: [insert incident reference number] (only include incident number if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Dispatch Time: [insert dispatch time] (only include dispatch time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) En Route Time: [insert en route time] (only include en route time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) At Scene Time: [insert time of arrival at scene] (only include at scene time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Transport Begin Time: [insert time transport began] (only include transport begin time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) At Destination Time: [insert time of arrival at destination] (only include destination time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Call Nature: [insert description of reason for call] (only include call nature if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Location: [insert address or site of incident] (only include location if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Dispatch Priority: [insert dispatch priority level] (only include dispatch priority if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) PATIENT DEMOGRAPHICS Name: [insert patient full name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) DOB: [insert patient date of birth] (only include date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Gender: [insert patient gender] (only include gender if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Address: [insert patient address] (only include address if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Phone: [insert patient phone number] (only include phone number if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Insurance: [insert insurance provider and ID] (only include insurance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Emergency Contact: [insert contact name, relationship, and number] (only include emergency contact if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Primary Care Physician: [insert physician name] (only include physician if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) SCENE ASSESSMENT Scene Safety: [insert description of scene safety] (write in one sentence; only include if scene safety is explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Number of Patients: [insert number of patients at scene] (only include if patient count is explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Mechanism of Injury/Nature of Illness: [insert type of incident or medical concern] (write in brief phrase; only include if mechanism or nature has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Additional Resources Required: [insert whether additional resources were needed] (only include if mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Location of Patient: [insert patient position and surroundings at scene] (write in one sentence; only include if patient location has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) PATIENT ASSESSMENT Chief Complaint: [insert patient’s presenting concern] (write in the patient’s own words if quoted; otherwise summarise briefly; only include if chief complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) History (SAMPLE): Signs/Symptoms: [insert reported symptoms and their progression] (write in sentence format; only include if signs/symptoms have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Allergies: [insert known drug or environmental allergies] (write as a list or phrase; only include if allergies have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Medications: [insert current medications reported or found] (write as a list or brief phrase; only include if medications have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Past Medical History: [insert relevant chronic or past conditions] (write as a list or phrase; only include if medical history has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Last Oral Intake: [insert what and when the patient last ate or drank] (write in phrase format; only include if oral intake is explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Events Leading: [insert description of events immediately preceding incident] (write in sentence format; only include if precipitating events are explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) PHYSICAL EXAMINATION General Appearance: [insert description of general presentation and posture] (write in sentence format; only include if general appearance has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Mental Status: [insert mental alertness and orientation] (write in sentence format; only include if mental status has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) HEENT: [insert findings from head, eyes, ears, nose, throat exam] (write in sentence format; only include if HEENT findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Respiratory: [insert observations of breathing pattern and lung sounds] (write in sentence format; only include if respiratory findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Cardiovascular: [insert heart rate/rhythm and auscultation findings] (write in sentence format; only include if cardiovascular findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Abdomen: [insert palpation and inspection findings] (write in sentence format; only include if abdominal exam findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Extremities: [insert any findings such as edema or mobility] (write in sentence format; only include if extremity findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Skin: [insert colour, moisture, and temperature of skin] (write in sentence format; only include if skin findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Neurological: [insert findings related to sensation, movement, or cranial nerves] (write in sentence format; only include if neurological findings have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Vital signs: Time: [insert each time vitals were collected] (only include if vitals timing has been explicitly mentioned.) BP: [insert blood pressure at corresponding time] (only include if BP is mentioned.) HR: [insert heart rate at corresponding time] (only include if HR is mentioned.) RR: [insert respiratory rate at corresponding time] (only include if RR is mentioned.) SpO2: [insert oxygen saturation at corresponding time and delivery method if applicable] (only include if SpO2 is mentioned.) Temp: [insert temperature if recorded] (only include if temperature is mentioned.) Pain (0–10): [insert patient’s self-reported pain score if obtained] (only include if pain scale is mentioned.) GCS: [insert Glasgow Coma Scale score at each time if evaluated] (only include if GCS is mentioned.) INTERVENTIONS Oxygen therapy: [insert flow rate, delivery method, and time started] (write in line format; only include if oxygen therapy has been explicitly mentioned.) Position: [insert position patient was placed in during care] (write in one line; only include if patient position has been explicitly mentioned.) Medication: [insert medication name, dosage, method, and time of administration] (write in line format; only include if medication has been administered and mentioned.) IV Access: [insert gauge, location, and time IV was established] (write in one line; only include if IV access has been established and mentioned.) Continuous cardiac monitoring: [insert rhythm interpretation and any noted events] (write in sentence format; only include if monitoring data has been mentioned.) TREATMENT RESPONSE [insert objective clinical changes observed following intervention, including respiratory, pain, or vitals] (write in paragraph format; only include if treatment response has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) TRANSPORT/HANDOFF INFORMATION Transport Decision: [insert whether emergency or non-emergency transport was used] (write in phrase format; only include if transport decision is explicitly mentioned.) Transport Position: [insert position patient was transported in] (write in phrase format; only include if transport position has been mentioned.) Report Given To: [insert name and role of clinician receiving handoff] (write in one line; only include if handoff recipient is mentioned.) Care Transferred: [insert time of transfer of care] (only include if time of transfer is explicitly mentioned.) Additional Notes: [insert any final logistical, family, or situational notes relevant to case conclusion] (write in sentence format; only include if additional notes have been explicitly mentioned.) SIGNATURES EMS Provider: [insert provider name and ID] (only include if provider details have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Patient Consent: [insert name of patient or representative if consent obtained] (only include if consent details have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Date/Time Completed: [insert date and time of final documentation entry] (only include if date/time completed has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)