Which statement is NOT appropriate to document in the narrative section of the PCR?

• A. Significant damage was noted to the front end of the vehicle.
• B. The patient admits to smoking marijuana earlier in the day.
• C. After oxygen was administered, the patient's breathing improved.
• D. General impression revealed that the patient was intoxicated.

Answer: (D)

In an EMS narrative, you document what you observe, what you hear from the patient, and how the patient responds to treatment, using objective language. You avoid labeling the patient with a diagnosis in the narrative unless there are clear, documented signs or test results to support it.

The statement about the patient being intoxicated uses a diagnostic label rather than describing observable signs. It asserts a cause without presenting concrete, observable evidence. In contrast, recording that the patient admitted marijuana use, that the scene showed significant damage, or that breathing improved after oxygen all rely on specific, observable data or direct patient statements and treatment responses. The narrative should convey those facts, and if intoxication is suspected, it’s better to note the patient’s statements and any observable cues (e.g., odor, slurred speech) rather than categorically labeling them as intoxicated.