This section of the patient-care report is most often used by the physician, insurance carrier or others who are interested in the patient's condition or treatment. Therefore, the EMS provider must complete this section of the form with great care, as it not only paints a picture of the patient but also of the author. A carelessly written report suggests that the patient's treatment was also carelessly provided, even though this is usually not the case. Use only black ink. If your writing is less than desirable, consider printing the narrative or completing the form using electronic or alternative media that may be available.
Correct spelling is essential.
If you don't know how to spell a word, look it up in a dictionary or select another appropriate word that you do know how to spell. Use only approved, standard abbreviations. If your agency does not provide you with a list of approved abbreviations, compile a list using a source like a local hospital. A list of many of the most common abbreviations are often included in EMT or paramedic textbooks. Use properly constructed sentences with correct grammar and punctuation.