Explain the purpose
Connect documentation to handoff, continuity of care, accountability, quality review, and useful EMS data.
Use fictional scenarios in this class and linked tools. Do not enter, paste, or upload a real patient report or patient-identifying information. The Narrative Coach may save drafts in this browser; the AI Writing Lab sends submitted text to an AI service for feedback. Use your agency-approved ePCR and field documentation process for actual calls.
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Your course checklist
Your 6 required steps
Follow the highlighted next step. Your progress is saved in this browser; your roster record is submitted when you finish the class.
- Not started1. Start classEnter your name.
- Not started2. Read class materialReview the class information below, then mark it complete.View class information →
- Not started3. Complete one guided narrativeUse the guided PCR template and generate a narrative.Open PCR Narrative Coach →
- Not started4. Complete one AI-graded narrativeSubmit a fictional narrative for a grade. Extra practice is optional.Locked until steps 1–3 are complete
- Not started5. Pass the written test (80%)Answer all 10 content questions and earn at least 8 correct.Go to written test →
- Not complete6. Finish classAvailable after the required steps and a passing test.
Start class to begin tracking your required steps.
By the end, you can
Build a clear, factual narrative
Separate facts
Distinguish what the patient said, what others reported, what you observed, what you assessed, and what you did.
Choose a structure
Compare chronological, CHART, SOAP, and DCHART while following your agency’s approved style.
Protect privacy
Keep real patient information inside systems and workflows your agency has approved.
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The standard
What makes a good EMS report?
A strong PCR lets another clinician or reviewer understand what happened, what the crew found, what care was provided, and how the encounter ended. Write in a logical order, use specific observations, and make each statement traceable to a source.
Include the relevant story
- Response and scene: call context, relevant scene conditions, and how the patient was found.
- Complaint and history: patient’s words and relevant information from family, bystanders, or caregivers, with the source identified.
- Assessment: pertinent findings, including positive and negative findings that were actually assessed.
- Timeline: initial and repeat vital signs with times or a clear sequence when they matter.
- Care and response: what was done and the documented response or change in condition.
- Disposition: transport or other disposition, transfer of care, and facts supporting the decision.
Keep the source clear
Patient reports: “Patient states pain began while walking.”
Witness reports: “Bystander reports the patient fell from standing.”
Crew observes: “Patient found seated on the floor, speaking in full sentences.”
Crew assesses: “Left wrist swollen; distal pulse present.”
Crew performs: “Wrist supported with a splint.”
Patient response: “Patient reports pain decreased from 6/10 to 4/10 after splinting.”
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Compare the writing
Vague wording versus useful detail
“Elderly patient fell. No injuries. Vitals normal. Treated and transported.”
- Does not show how the crew reached “no injuries” or “normal.”
- Leaves out the patient’s account, assessment, care, response, and timeline.
- Does not help a reader reconstruct the encounter.
“Patient states she slipped while stepping out of the shower and denies loss of consciousness. Crew found the patient seated on the bathroom floor. Patient reports left wrist pain rated 6/10. At 0718, BP was 148/86, pulse 88, respirations 18, and SpO₂ 97% on room air. The wrist was supported with a splint. At 0730, patient reported pain of 4/10. Patient was transported to the receiving facility and care was transferred to the receiving nurse.”
- Identifies who supplied the information.
- Records specific findings and times instead of unsupported labels.
- Shows care, response, transport, and handoff.
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Avoid common problems
What should and should not be in a report
Do
- Use neutral, professional language and observable descriptions.
- Attribute statements to the person who made them.
- Document only findings, care, times, and responses supported by what happened.
- Explain relevant changes and reassessments in sequence.
- Follow local ePCR fields, approved abbreviations, policy, protocol, and state requirements.
Avoid
- Judgmental labels, sarcasm, blame, or speculation about motive.
- “Normal,” “stable,” “uninjured,” or “denies” when the supporting assessment or statement is absent.
- Generic copied text that does not describe this patient and encounter.
- Contradictions between narrative, times, vital signs, treatment record, or disposition.
- Unnecessary detail that does not clarify care, safety, or the encounter.
- Real patient identifiers in this public training class, template, or AI grader.
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Choose a format
Common report styles: advantages and tradeoffs
These formats organize a narrative; they do not replace your agency’s requirements. Acronym definitions and local expectations can differ. Keep the same facts and timeline whichever format you use.
| Style | Typical organization | Advantages | Tradeoffs |
|---|---|---|---|
| Chronological | Dispatch and arrival → history → assessment → care and reassessment → disposition and handoff. | Easy to follow event sequence and see changes over time. | Can become long or repetitive unless the writer stays focused. |
| CHART | Chief complaint → History → Assessment → Rx/treatment → Transport. | Familiar sections help organize a complete call. | May feel like separate boxes; timing and transitions can get lost. |
| SOAP | Subjective → Objective → Assessment → Plan. | Separates reported information from observed findings and organizes impression and plan. | Can obscure the operational timeline; “Assessment” should not become an unsupported diagnosis. |
| DCHART | Dispatch → Chief complaint → History → Assessment → Rx/treatment → Transport. | Calls attention to dispatch and transport as part of the encounter. | Can feel checklist-driven; local expansions and required details may vary. |
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Protocol-informed documentation
Use your current local protocol as a writing checklist
The Denver Metro EMS Medical Directors’ protocols are organized by protocol number and condition/procedure. Their introduction says protocols support decision-making, may not cover every scenario, and may require clinically justified variance. When writing a report, review the current protocol(s) that apply to the encounter and your agency’s implementation, ePCR fields, and documentation policy.
Capture the applicable parts
- State the working complaint or presentation and document the protocol-relevant history and assessment findings, including pertinent positives and negatives actually assessed.
- Record protocol-required measurements, times, reassessments, and changes in condition; include the patient’s response to each intervention.
- Describe treatments, procedures, medications, and destination or notification steps that were actually completed, including relevant dose/route/time details in the appropriate ePCR fields.
- Document required Base Contact or medical direction: who was contacted, when, the clinical question or information shared, the direction received, and actions taken, as applicable to your system.
- If care varied from protocol, document the clinical reasoning, patient-specific circumstances, consultation or approval when obtained, and what happened next. Follow agency procedures for review.
Document weight-based medication math
For any weight-based medication, document the patient’s dosing weight and units, and identify whether it was measured, estimated, or obtained from an approved length-based system. If the dose uses kilograms and the weight was obtained in pounds, record the conversion method and the kilogram value used.
Show the calculation so another reviewer can follow it: weight (kg) × ordered dose (mg/kg) = calculated dose (mg). Document any maximum-dose adjustment and the actual dose given in mg. If converting to a volume, show dose (mg) ÷ concentration (mg/mL) = volume (mL). Include route, time, and patient response in the appropriate medication fields and narrative as required by your ePCR and local policy. If a weight cannot be obtained, follow the current protocol and document the approved estimate or dosing system used—never invent a weight.
Denver Metro Protocol 9000 recommends a standardized age-, weight-, or length-based system for every pediatric patient. Use your agency’s current approved method and cross-check the calculation before administration.
Identify the protocol when useful or required
When your agency requires or the narrative benefits from it, name the protocol actually used and include its number (and version/date if needed to distinguish it). Use the local protocol title and number exactly as published—for example, “Denver Metro Protocol 3060, Chest Pain,” only when that protocol was in effect for your agency and applied to the call.
If more than one protocol guided care, identify the applicable protocols without implying steps you did not perform. Do not add a protocol number as a substitute for documenting the assessment, treatment, response, consultation, or clinical reasoning.
Example framework: “Care provided under [agency protocol title/number and version, if required]. [Relevant assessment and timeline]. [Interventions and response]. [Consultation or variance and rationale, if applicable].” Replace every bracket with verified facts; follow your ePCR structure.
Denver Metro reference: Denver Metro EMS Medical Directors — current protocols and revision materials (the site identifies its July 2026 protocols as current). See General Guidelines 0010, 0020, 0031, 0032, 0120, and the protocol specific to the call. Agencies may have locally approved changes or different versions; verify what applies to your service.
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Special situations
Write clearly when the call does not follow the usual path
Use the same rules—source, objective detail, sequence, and accuracy—when a patient refuses, an assessment is limited, or the encounter ends without transport. Follow your service’s approved workflow and local requirements.
Refusal or non-transport
Make clear what the patient declined (assessment, treatment, or transport); document capacity, the care offered, risks explained and understood, the patient’s decision and stated reason, alternatives discussed, and the final disposition. Follow your current local refusal protocol and agency form.
Identify the authorization path: document the base-contact physician’s name and direction when consultation is required, or identify the applicable standing-order protocol and confirm the criteria were met when that pathway is authorized for your agency by its Medical Director. Never imply that a physician was contacted when one was not.
Obtain the patient or authorized representative’s signature and a witness signature on the agency refusal form. For this class, include a witness signature whenever a witness is available; record the witness’s name and role. If the patient or witness declines or no witness is available, document that fact and follow agency procedure.
Denver Metro Protocol 0032 calls for the authorizing Base Contact physician’s name unless the standing-order pathway applies, and a signed refusal form if possible. Its documentation list does not specify a witness signature, so verify the witness requirement in your agency’s policy and form.
Limited or unobtainable assessment
State which information or measurement could not be obtained, what was attempted, and the documented reason or patient response. Distinguish “not assessed,” “unable to obtain,” and “patient declined” when your ePCR allows it. None of those means “normal.”
No patient contact or changing condition
For canceled calls, no-contact encounters, or a patient whose condition changes, document what actually happened and follow your agency’s disposition fields. For changes, place the relevant findings, times, actions, and response in sequence.
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Corrections and late entries
Correct the record transparently
If you find an error after signing
- Use your ePCR’s approved correction or amendment process.
- Do not silently overwrite the signed report, backdate an entry, or make a change you cannot verify.
- Identify the corrected information and follow required author, date/time, and reason fields.
- Preserve the original report and its audit trail as required by agency procedure.
If you need a late entry
Follow agency policy for late entries. Make clear that it is a later entry, who made it, when it was entered, what event/time it relates to, and why it was added when those details are required. Keep the added information factual and verifiable.
Read the NEMSIS PCR Data QuickGuide on amendments and retaining reports →
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Privacy and field boundaries
HIPAA: protect patient information
Patient information handled by EMS organizations must be protected under applicable privacy and security requirements. HIPAA compliance depends on the organization’s policies, systems, vendors, access controls, and workflows; using a template or removing a name alone does not make a tool appropriate for real patient information.
For this class
Use fictional scenarios. Never paste a real PCR, names, dates of birth, addresses, phone numbers, incident numbers, exact locations, images, or details that could identify a patient.
For actual calls
Document in the agency-approved ePCR and follow agency policy. Do not use EMSCodeSim’s public practice tools to create, store, or submit real patient reports.
For AI practice
The AI Writing Lab sends submitted narrative text to an AI service for educational grading. Feedback can be imperfect and is not clinical or protocol review. Keep submissions fictional.
Official references: NEMSIS PCR Data QuickGuide · HHS HIPAA Security Rule summary · HHS minimum necessary guidance · CMS ambulance documentation guidance
Class information reviewed?
After reviewing the report-writing, protocol, refusal, correction, and privacy sections above, mark this step complete to unlock the guided narrative.
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Practice and revise
Use the EMSCodeSim tools in this order
Build with a template
Choose a fictional call in the PCR Narrative Coach. Complete relevant sections, select chronological, SOAP, CHART, or DCHART, then check every generated sentence against the facts you entered. Remove anything unsupported.
Open the PCR Narrative Coach →Write independently
Select a fictional scenario in the AI Narrative Writing Lab and write your own report. The grader supports chronological, CHART, and SOAP. The Coach also offers DCHART for template practice.
Open the AI Narrative Writing Lab →Use feedback, then revise
Review rubric scores, missing facts, unsupported statements, contradictions, and sentence-level feedback. Compare comments with the scenario facts, revise, and resubmit. Treat the score as coaching, not an official evaluation.
Try a second format
Write the same fictional call in another supported format. Check whether a reader can follow the source of each fact, timeline, care, response, and disposition.
Capstone: self-score, then revise
Choose a fictional case in the AI Narrative Writing Lab. Before asking for a grade, write a complete narrative in a supported format and use the checklist below. Then compare your self-review with the AI feedback and revise only facts supported by the case.
Self-review checklist before grading
- Did I identify who supplied each history detail?
- Can a reader follow the encounter in order?
- Are the findings and vital signs specific and tied to the scenario?
- Did I describe care, reassessment, and the patient’s response?
- Did I explain the disposition and handoff using only supplied facts?
- Did I avoid invented normal findings, unsupported negatives, and identifiers?
If the grader suggests adding a fact that is not in the scenario, leave it out. Ask an instructor to review questions the AI feedback does not resolve.
What the AI grader reviews
CompletenessAccuracy to scenario factsOrganizationObjectivityPertinent negativesMedical necessity narrativeDocumentation safetyWriting quality
The grader compares writing with the fictional scenario. It does not verify a real encounter, determine protocol compliance, or replace instructor or agency review.
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Knowledge check
Check your understanding
A patient says, “I’m not dizzy.” The crew did not assess gait. Which statement is better?
Answer: Attribute it: “Patient denies dizziness.” Do not add “steady gait” unless it was observed or assessed.
The narrative says “vitals normal,” but lists no measurements or time. What is the problem?
Answer: “Normal” is vague and cannot be checked. Record the measurements, relevant times, and changes instead of relying on a summary label.
A practice report is based on a real call. What should be used for an external training exercise?
Answer: Use a fictional scenario without patient-identifying details. Removing only a name does not necessarily make a real report appropriate to share.
Which report format is automatically the most accurate?
Answer: None. Choose a format accepted by your agency and ensure facts are complete, objective, correctly attributed, and consistent.
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Written test and completion record
Written test and class completion
After completing the guided narrative and one AI-graded narrative, answer all 10 content questions. You need at least 8 correct (80%) to pass. If you do not pass, review the material and try again. When every step is complete, select Finish class. The roster stores your name, passing test score, first AI narrative score, and completion time. It does not store your email or narrative text. Never use real patient information.
Department administrator: view or print the class roster →
Complete the AI-graded narrative before taking this test. You may submit extra narratives for practice; only the first required AI grade is recorded.
Open AI narrative grading →Ready to practice?
Build one report, grade one report, revise one report.
Start with a fictional case and focus on one improvement at a time.