Every time an EMS unit is dispatched to a call, a Patient Care Report (PCR) must be generated (regardless if the ambulance made it to the scene or did not see a patient). Currently, all PCR’s are inputted into NEMSIS/GEMSIS compliant database, usually completely inputted by EMS personnel after each call with a laptop.

The PCR serves many purposes. The primary purpose of the document is to follow the patient through the continuum of care as a reference document. A PCR is often used to justify a billing report sent to an insurance company. In some cases the PCR is used for legal purposes (in the event the call results in some type of legal action).

Minimally, the PCR maintains a record of the time of each event of the call (EMS unit dispatch, arrival, time patient contact made, and times the patient was transported and arrived at the hospital. A well written PCR must include assessment findings, observations at the scene, and emergency medical care provided (including what was done prior to arrival). Documentation of any improvements that were seen by the EMS crews and how the call was resolved (disposition). Not every EMS call results in transport, sometimes the patient is turned over to a different unit, sometimes the patient is transported to the hospital, and other times the patient may refuse transport.