Accurate paramedic documentation standards are essential for:
- Continuity of Care: EMS call report examples provide hospital staff with critical patient information, ensuring seamless transitions.
- Legal Protection: Detailed EMS narrative report templates protect providers and agencies from liability by documenting care accurately.
- Billing and Reimbursement: Precise prehospital care report templates ensure compliance with insurance requirements, maximizing revenue.
- Quality Improvement: EMS documentation templates enable agencies to analyze trends and improve protocols.
However, manual documentation is time-consuming and error-prone, leading to incomplete records and increased stress. AI and healthcare solutions like S10.AI address these challenges by automating EMT report writing examples, saving time, and improving accuracy.
AI medical scribes like S10.AI’s CRUSH act as trusted digital assistants, listening to patient-provider interactions and generating real-time EMS patient care report examples in standardized formats like SOAP or CHART. Compatible with all medical specialties and EHR systems (e.g., Epic, Cerner, Athenahealth), these tools AI transcribe conversations, populate templates, and ensure compliance with paramedic documentation standards. Here’s how they help:
- Time Savings: Reduce documentation time by up to 95%, freeing EMS providers for patient care.
- Accuracy: Minimize errors in EMS narrative report templates by capturing nuanced details automatically.
- Burnout Reduction: Alleviate administrative stress, allowing providers to focus on human interaction.
- Scalability: Integrate with any EHR, making it ideal for EMS agencies of all sizes.
Dr. Claire Dave, a physician and AI advocate at S10.AI, shares: “Our CRUSH AI scribe has transformed EMS workflows. Paramedics report a 50% reduction in after-shift documentation time, allowing them to leave work on time and focus on patient care. This directly reduces burnout and improves job satisfaction.”
Below, we provide a comprehensive EMS report template with examples to guide paramedics and EMTs in creating accurate and efficient prehospital documentation. This template follows the SOAP format, widely used in EMS for its clarity and structure.
Subjective
Chief Complaint: Patient’s stated reason for the call (e.g., “I’m having chest pain”).
History of Present Illness: Use OPQRST or SAMPLE to detail symptoms, onset, duration, and medical history.
Patient Statements: Direct quotes from the patient or bystanders.
Objective
Vital Signs: Record heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature.
Physical Exam: Document findings from head-to-toe assessment.
Interventions: List treatments provided (e.g., oxygen, IV fluids, medications).
Assessment
Primary Impression: Suspected diagnosis based on findings (e.g., suspected myocardial infarction).
Differential Diagnoses: Other possible conditions.
Plan
Treatments Administered: Detail medications, dosages, and routes.
Transport Decision: Hospital destination and mode (e.g., lights and sirens).
Handover: Note the receiving clinician and patient disposition.
Subjective
A 62-year-old male presents with a chief complaint of “chest pain for 30 minutes.” Patient describes the pain as sharp, radiating to the left arm, with associated nausea. Denies recent trauma. Medical history includes hypertension and smoking (20 pack-years). Current medications: Lisinopril 10mg daily. No known allergies.
Objective
Vital Signs: BP 160/100 mmHg, HR 88 bpm, RR 18, SpO2 96%, Temp 98.7°F.
Physical Exam: Alert and oriented, diaphoretic, no visible trauma. Heart sounds normal, lungs clear.
Interventions: Administered 324mg aspirin orally, 4L/min oxygen via nasal cannula.
Assessment
Primary Impression: Suspected acute coronary syndrome.
Differential Diagnoses: Angina, pulmonary embolism, aortic dissection.
Plan
Treatments: Nitroglycerin 0.4mg sublingual administered.
Transport: Transported to St. Mary’s Hospital via ambulance (priority 1).
Handover: Patient transferred to Dr. Johnson in the ER, report provided.
The best EMS report template for paramedics balances structure with flexibility. The CHART format is another popular option, offering a narrative-driven approach.
Chief Complaint
Patient’s primary issue in their own words.
History
Medical history, allergies, medications, and events leading to the call.
Assessment
Vital signs, physical findings, and diagnostic results.
Rx (Treatment)
Interventions performed and patient response.
Transport
Destination, mode, and handover details.
Chief Complaint
“Shortness of breath,” reported by a 45-year-old female.
History
History of asthma, uses albuterol inhaler. Symptoms began 1 hour ago after exposure to smoke. Denies other complaints.
Assessment
Vital Signs: BP 130/80 mmHg, HR 110 bpm, RR 24, SpO2 92%, Temp 99°F.
Physical Exam: Wheezing bilaterally, no cyanosis.
Diagnostics: Peak flow 250 L/min.
Rx
Albuterol 2.5mg via nebulizer, improved SpO2 to 98%.
Patient Response: Breathing eased, wheezing reduced.
Transport
Transported to General Hospital, non-emergent.
Handover: Report given to Nurse Thompson in the ER.
Free Printable EMS Report Templates: Access our CHART template for quick and accurate documentation. Learn more about S10.AI’s AI medical scribe.
Writing an effective EMS report requires clarity, accuracy, and adherence to paramedic documentation standards. Follow these steps:
1. Start Immediately: Complete the EMS documentation template as soon as possible to avoid forgetting details.
2. Use Standardized Formats: Choose SOAP or CHART for consistency.
3. Be Objective: Avoid assumptions (e.g., “slurred speech, odor of alcohol” instead of “patient was drunk”).
4. Include Timelines: Document dispatch, arrival, and transport times for billing and quality assurance.
5. Detail Interventions: Record medications, dosages, and patient responses.
6. Use AI Tools: Leverage AI medical scribes like S10.AI to automate note-taking and ensure compliance.
Narrative: On 08/09/2025 at 14:30, dispatched to 123 Main St. for a 30-year-old male with a laceration. Arrived at 14:38, found patient alert with a 5cm laceration on the left forearm, bleeding moderately. Patient denies loss of consciousness or other injuries. Applied sterile dressing and pressure bandage, bleeding controlled. Vital signs: BP 120/80 mmHg, HR 76 bpm, RR 16, SpO2 99%. Transported non-emergent to City Hospital, arriving at 15:00. Handed over to Dr. Lee with a full report.
Artificial intelligence in healthcare is revolutionizing EMS run report templates. S10.AI’s CRUSH AI scribe integrates with EHR systems like Epic, Cerner, and Athenahealth, offering:
- Real-Time Transcription: Captures patient interactions and populates EMS call report examples instantly.
- Customizable Templates: Adapts to agency-specific EMS narrative report templates.
- Compliance: Ensures adherence to NEMSIS and insurance standards.
- Burnout Reduction: Saves hours of documentation time, improving work-life balance.
Burnout among EMS providers is a growing concern, with 70% reporting high levels of emotional exhaustion. AI toolslike S10.AI’s CRUSH alleviate this by:
- Reducing administrative workload.
- Improving documentation accuracy.
- Allowing more time for patient interaction.
- Enhancing job satisfaction through streamlined workflows.
“Since adopting S10.AI’s CRUSH, our team spends less time on paperwork and more time with patients. It’s a lifesaver for morale and efficiency.” — Paramedic John Smith, City EMS.
1) What is an AI medical scribe?
An AI medical scribe is an artificial intelligence tool that transcribes patient-provider interactions, generates EMS patient care report examples, and integrates with EHR systems like Epic and Cerner, saving time and reducing errors.
2) How do I write an EMS report with examples?
Follow a standardized format like SOAP or CHART, start immediately, remain objective, include timelines, detail interventions, and use AI tools like S10.AI for automation. See examples above.
3) What is the best EMS report template for paramedics?
The SOAP and CHART formats are the most effective due to their structured approach and compatibility with prehospital documentation standards. Download free templates here.
4) How does AI reduce burnout in EMS?
AI in healthcare automates repetitive tasks, reduces documentation time, and improves accuracy, allowing EMS providers to focus on patient care and reduce stress.
5) What documentation frameworks are commonly used in EMS report templates (e.g., SOAP, CHART, DACHARTE)?
While there’s no one-size-fits-all mandate for EMS report formats, many clinicians rely on proven frameworks that boost clarity and consistency. Among the most widely used are:
SOAP (Subjective, Objective, Assessment, Plan): This classic framework helps structure reports by breaking down the patient's story, clinical findings, clinician impressions, and planned interventions. It’s favored for its adaptability across healthcare settings.
CHART (Chief complaint, History, Assessment, Rx/treatment, Transport): CHART streamlines information according to the typical EMS encounter sequence, making it straightforward for both field providers and hospital staff to follow.
DACHARTE (Dispatch, Assessment, Chief complaint, History, Assessment [again], Rx/treatment, Transport, Evaluation): DACHARTE takes a comprehensive approach, guiding clinicians to capture every step from dispatch to outcome.
These frameworks serve as trusted blueprints for EMS documentation, helping providers stay organized and communicate vital information efficiently. Starting with a structured template not only minimizes omissions but allows for seamless adaptation as you gain experience and refine your documentation style.
6) What are some examples of EMS report templates, such as DACHARTE format and narrative templates?
While SOAP is a mainstay in many EMS systems, paramedics and EMTs also rely on alternative documentation frameworks tailored to different agency protocols and preferences. Here are several widely used EMS report templates:
DACHARTE Format: This structured approach stands for Discharge, Arrival, Chief Complaint, History, Assessment, Rx (Treatment), Transport, and Exceptions. Each section prompts medics to capture essential details chronologically, ensuring nothing falls through the cracks—especially useful for multi-step incidents.
EMS Narrative Template: For clinicians who prefer more flexibility, narrative templates allow for a continuous, story-driven report. These typically guide the user to document the entire call sequence—beginning with dispatch and arrival, reviewing patient history and assessment findings, describing all interventions, monitoring and transport details, and concluding with hospital handover notes and any additional comments.
Handoff Report Template: Effective transitions of care hinge on clear, concise handoff reports. These templates emphasize documenting a snapshot of the incident, scene assessment, a focused physical exam, interventions performed, treatment responses, and handover specifics. They are especially valuable when transferring patients to emergency room teams or specialty centers.
Most modern EMS documentation platforms—such as those integrating with Epic, Cerner, or ePCR solutions—provide customizable versions of these templates to match agency workflows and regulatory requirements.
7) How can EMTs write clearly and coherently in their reports?
When crafting your EMS report, aim for straightforward language that leaves no room for confusion. Use complete sentences and arrange facts in a logical sequence, so any reader—whether it’s another paramedic, a physician, or legal personnel—can easily follow the event timeline.
Steer clear of excessive acronyms or specialized jargon, especially terms flagged by organizations like The Joint Commission as potentially confusing or unsafe. Instead, opt for plain English whenever possible. This not only improves clarity but also ensures your documentation stands up to scrutiny and supports optimal patient care decisions.
8) How can clinicians create or customize their own EMS report templates?
Paramedics and clinicians often need documentation tools tailored to their agency’s workflow or local protocols. Fortunately, creating or customizing your own EMS report template doesn’t have to be complicated—here’s how to get started:
Start with a Proven Framework: Select a widely used EMS reporting format, such as SOAP or CHART, as your foundation. These formats are familiar across the industry and ensure consistency.
Adapt an Existing Template: Agencies can take a template from platforms like Epic, Cerner, or other EHR libraries, then adjust fields or sections to suit specific documentation requirements—such as adding region-specific protocol checkboxes or narrative prompts.
Use Examples: Draft your own template by modeling it after example EMS reports. Many professional organizations, such as NAEMT or JEMS, publish sample narratives and template guidelines to inspire your structure.
Leverage Feedback: Share your draft template with colleagues or training officers and incorporate their insights. Real-world feedback helps refine fields and prompts for accuracy and usability.
Test and Tweak: Pilot your customized template during ride-alongs or drills. Make adjustments based on ease of use, compliance with state or hospital requirements, and whether the final report captures all critical information without redundancy.
By combining established structures with thoughtful customization, you can build an EMS report template that balances regulatory compliance, documentation quality, and workflow efficiency.
9) What are the key sections of an EMS PCR, such as dispatch information, patient demographics, scene assessment, and handover details?
An effective EMS PCR—sometimes also called a prehospital care report—typically contains several crucial sections to ensure thorough documentation and continuity of care. Here’s what you’ll find in a well-structured PCR:
Dispatch Information: Notes the initial call details, including the incident location, chief complaint, and times for dispatch, en route, arrival, and departure.
Patient Demographics: Basic information such as name, age, gender, and pertinent medical history.
Scene Assessment: A summary of the situation upon arrival, including safety considerations, environmental details, and observations that may impact patient care.
Head-to-Toe Assessment: Documentation of findings from the physical examination, highlighting injuries, symptoms, and baseline vital signs.
Interventions and Treatments: A record of all treatments and procedures performed in the field, from medication administration to airway management.
Ongoing Monitoring: Tracking of vital signs, patient response to interventions, and any notable changes during transport.
Handover Details: Information shared upon transfer of care, detailing all relevant events and treatments provided during prehospital care.
With these components, an EMS PCR provides a structured snapshot of each patient encounter—critical both for quality care and future reference.
10) What is an EMS PCR (Prehospital Care Report) and how is it structured?
An EMS Prehospital Care Report (PCR) is the official record that paramedics and EMTs complete to document every patient encounter before arrival at the hospital. Think of it as the backbone of EMS communication—ensuring nothing slips through the cracks between the field and the ER.
A typical PCR is organized into several key sections, including:
Dispatch Details: Basic information such as call location, reason for dispatch, and response times.
Patient Demographics: Age, gender, medical history, and contact information.
Scene Assessment: Observations and findings at the scene, including environment and potential hazards.
Physical Assessment: A systematic head-to-toe review of the patient’s condition.
Interventions and Monitoring: Treatments provided, medications administered, and ongoing monitoring of vital signs.
Patient Response: Notes on how the patient responded to EMS care.
Handover Information: Summary provided to hospital staff during the transition of care.
By following this organized template, EMS teams ensure every critical detail is captured, promoting effective patient care, strong legal documentation, and efficient teamwork from the field to the hospital.
11) What is the DACHARTE framework for EMS documentation and what does each section represent?
The DACHARTE framework is another widely used structure for EMS report writing, designed to streamline call documentation while ensuring nothing essential is overlooked. Each letter in DACHARTE stands for a specific section you should include:
Discharge: Document the patient's condition at the end of care—whether they were transferred, released, or left against medical advice.
Arrival: Record the circumstances on arrival, such as scene safety, first impressions, and bystander information.
Chief Complaint: Detail the main concern in the patient’s or bystander’s own words.
History: Capture relevant medical history, current medications, allergies, and the events leading up to your arrival.
Assessment: Thoroughly document findings from your physical exam and vital signs.
Rx (Treatment): Outline any interventions performed, including medications, procedures, or supportive care.
Transport: Specify transport decisions, patient status en route, destination, and mode (e.g., urgent, non-emergent).
Exceptions: Note any unusual factors, deviations from protocol, or extenuating circumstances impacting care.
This systematic approach is popular among agencies like the National Association of Emergency Medical Technicians (NAEMT) and helps ensure a well-rounded, professional EMS report.
12) Why is it important to minimize the use of acronyms and jargon in EMS reports?
While EMS narratives often require concise writing, relying too heavily on acronyms and medical jargon can backfire. Using unfamiliar shorthand can confuse hospital staff, slow down care transitions, and even introduce dangerous misunderstandings—especially if terms aren’t universally recognized or appear on “do not use” lists published by groups like The Joint Commission.
To promote clarity and patient safety, EMTs and paramedics should prioritize plain language whenever possible. This simple adjustment ensures everyone reviewing the report—from ER clinicians to billing specialists—can quickly understand the situation without deciphering ambiguous abbreviations or insider terminology.
13) What kind of prompts or fields might be included in advanced EMS report templates to cover high-liability issues?
Modern EMS report templates go beyond the basics by incorporating specialized prompts to address scenarios with heightened legal and clinical risk. Fields you’ll often see in these robust templates include:
Refusal of Care: Document the patient’s decision, their mental status at the time, the risks explained, alternative care options discussed, and signatures (patient, witness, provider) to demonstrate informed refusal.
Substance Use/Intoxication: Capture current substance use (including type and route), observed effects (e.g., slurred speech, altered mentation), and any interventions to ensure patient and provider safety.
Capacity Assessment: Prompt for a focused evaluation of the patient’s ability to understand and make decisions, which is critical in refusals or cases involving altered mental status.
Informed Consent: Fields ensuring a clear record that the patient was educated about risks, benefits, and alternatives before any procedure or transport.
Police or Protective Custody: Space to note law enforcement involvement, custody decisions, restraints used, and communication with officials—common with psychiatric or substance-related calls.
Social and Environmental Factors: Prompts for documenting bystander input, home environment hazards, and any safeguarding steps taken for vulnerable individuals.
Advanced templates from leading EHR vendors (such as Epic, Cerner, or ImageTrend) frequently incorporate these sections, ensuring clinicians capture all elements vital for both clinical care and legal compliance.
EMS report templates with examples are essential for efficient, accurate, and compliant prehospital care report templates. By integrating AI medical scribes like S10.AI’s CRUSH with EHR systems like Epic, Cerner, and Athenahealth, EMS providers can save time, reduce burnout, and enhance patient care. Whether you’re a paramedic or EMT, adopting artificial intelligence in healthcare is a strategic investment in productivity and well-being.
How can I write a more effective EMS patient care report narrative that includes all essential elements for billing and handoff?
To enhance your EMS patient care report (PCR) narrative, focus on creating a comprehensive and clear picture of the patient encounter. Start with the dispatch information, the reason for the call, and a detailed description of the scene upon arrival. Document the patient's condition, including their position and any initial complaints. Thoroughly record your physical assessment findings, all interventions performed with the patient's response to each, and any changes in the patient's status during transport. Ensure you include all vital signs, medications administered with dosages, and the supplies used. For a truly effective narrative that supports billing and continuity of care, it's crucial to be detailed and accurate. Explore how AI scribes can help you capture all essential data points in real-time, ensuring your PCR is complete and clinically precise.
What are the critical components of an EMS pre-hospital radio report to ensure a smooth patient handover to the emergency department?
A concise and structured pre-hospital radio report is key to a seamless patient handover. Your report should be delivered in a professional manner and last approximately 60-90 seconds. Begin by identifying your unit and personnel. State the patient's priority level (e.g., Priority 1 for critical, unstable patients) and the nature of the call. Provide the patient's demographics (age and gender) and their chief complaint. Relay the most recent vital signs and any immediate concerns you have. Detail the treatments you have provided and any requested interventions. Conclude with your estimated time of arrival (ETA) at the emergency department. Consider implementing a standardized template for your radio reports to ensure consistency and clarity, which can significantly improve patient outcomes.
What specific details should be included in the history of present illness (HPI) and physical exam sections of an EMS report for a patient with altered mental status?
When documenting the history of present illness (HPI) for a patient with altered mental status, it's vital to gather information from all available sources, such as family or bystanders. Note the patient's baseline mental status if known, the onset and duration of the altered state, and any associated symptoms like fever, headache, or trauma. For the physical exam, a detailed neurological assessment is crucial. This should include the Glasgow Coma Scale (GCS) score, pupil size and reactivity (PERL), and motor function. Document the patient's skin condition, vital signs, and blood glucose level. A thorough report will paint a clear clinical picture for the receiving facility. Learn more about how advanced documentation tools can help you capture these critical details accurately and efficiently, even in the most chaotic situations.
Hey, we're s10.ai. We're determined to make healthcare professionals more efficient. Take our Practice Efficiency Assessment to see how much time your practice could save. Our only question is, will it be your practice?
We help practices save hours every week with smart automation and medical reference tools.
+200 Specialists
Employees4 Countries
Operating across the US, UK, Canada and AustraliaWe work with leading healthcare organizations and global enterprises.