THE WILD GUIDE
PATIENT CARE
NOTES RESOURCES
Instructions, examples, and training resources for Field Patient Care Notes.
EMS • WFR • SAR • SKI PATROL • FIRST RESPONDERS • GUIDES
FIELD DOCUMENTATION FOR TRAINING & PATIENT CARE
Field Patient Care Notes provides a structured format for documenting patient assessment, history, serial vital signs, treatment, reassessment, evacuation, and handoff.
It is designed for use in the field as well as during EMT, wilderness medicine, rescue, ski patrol, and first responder training.
WHAT'S INSIDE
FIELD PATIENT CARE NOTES
Patient Care Note Sets
Complete four-page documentation sets for patient encounters, simulations, and documentation practice.
Refusal Forms
Two-page informed refusal documentation including decision-making capacity and provider/witness documentation.
Primary Assessment & Life-Threat Checklist
A compact primary-survey reference for identifying and treating immediate life threats.
Operational Radio Report
A simple format for communicating unit/location, conditions, actions, and resource needs.
Medical Handoff Template
A structured format for concise medical reporting and patient handoff.
Built for Practice
Useful for field documentation, EMT/WFR training, patient scenarios, and documentation practice.
START HERE
HOW TO USE THE NOTEBOOK
Use one complete four-page set for each patient or training scenario.
INITIAL ASSESSMENT & OPERATIONAL DECISION
Document the initial patient presentation, chief complaint or story, primary survey, patient priority, and early evacuation/resource considerations.
PATIENT HISTORY
Document OPQRST-I, SAMPLE+R, and other pertinent history.
PHYSICAL EXAM & SERIAL VITAL SIGNS
Record significant examination findings, document your working impression, and trend serial vital signs throughout care.
TREATMENT • REASSESSMENT • EVACUATION
Document treatments and interventions, patient response, reassessment, and final evacuation or transfer disposition.
VIDEO INSTRUCTIONS
PATIENT CARE NOTE WALKTHROUGH
Follow a patient encounter through the complete four-page documentation process.
VIDEO COMING SOON
Replace this box with your Squarespace Video Block when your walkthrough is ready.
VIDEO INSTRUCTIONS & EXAMPLES
LEARN THE SYSTEM
These resources are designed to help users understand both the documentation workflow and the communication tools built into the notebook.
Patient Care Note Walkthrough
See how to complete the four-page Patient Care Note from initial contact through evacuation and handoff.
COMING SOONDocumentation Tips
Learn how to document clearly, objectively, and concisely while capturing clinically important information.
COMING SOONCompleted Patient Examples
Review completed examples showing an appropriate level of detail for realistic patient documentation.
COMING SOONMedical Radio Report Examples
Hear or read examples of concise patient reports using the IMIST-AMBO medical handoff format.
COMING SOONUCAN Operational Update Examples
Practice communicating location, conditions, actions, and resource needs quickly and clearly.
COMING SOONRefusal Form Guidance
Review decision-making capacity, informed refusal documentation, patient acknowledgment, medical control, and witness documentation.
COMING SOONFIELD COMMUNICATION
OPERATIONAL UPDATE & MEDICAL HANDOFF
INITIAL OPERATIONAL UPDATE
Give UCAN early—request resources as soon as needs are identified.
- U — Unit / Location
- Identify your unit/team and current location.
- C — Conditions
- Briefly describe what happened, patient count, patient priority, and important scene or access concerns.
- A — Actions
- State what assessment, treatment, or evacuation actions are underway.
- N — Needs
- Request needed resources and identify the rendezvous, access, or transfer point.
EMS/ALS • litter team • ground evacuation/UTV • technical rescue • medical aircraft • hoist/technical aircraft
MEDICAL REPORT / HANDOFF
Provide once sufficient patient information is available.
- I — Identification
- Patient age and sex/gender.
- M — Mechanism / Medical Complaint
- Mechanism of injury or chief medical complaint.
- I — Injuries / Important Findings
- Significant findings and pertinent negatives.
- S — Signs & Trends
- Vital signs, mental status, and important trends.
- T — Treatment
- Treatments provided and patient response.
- A — Allergies
- Pertinent allergies or NKDA.
- M — Medications / Medical History
- Pertinent medications and relevant medical history.
- B — Background
- Relevant events, timeline, or environmental factors.
- O — Other / Evacuation Plan
- Transport plan, destination/transfer point, ETA, and special concerns.
TRAINING & EDUCATION
FOR STUDENTS & INSTRUCTORS
FOR STUDENTS
Use the notebook during EMT, WFR, rescue, and first responder scenarios to practice organizing assessment findings and producing clear patient documentation.
One four-page Patient Care Note set can be used for each simulated patient encounter.
FOR INSTRUCTORS
Incorporate Patient Care Notes into simulations to reinforce patient assessment, clinical decision-making, documentation, reassessment, evacuation planning, and handoff.
Documentation can also become part of the scenario debrief: What did the student identify? What changed? What did they treat? What did they communicate?
BUILT-IN QUICK REFERENCES
ASSESS • DOCUMENT • COMMUNICATE
FIELD PATIENT CARE NOTES
INTERESTED IN A COPY?
Field Patient Care Notes is currently being prepared for release. If you are interested in purchasing a copy, using the notebook in a course, or discussing classroom quantities, contact The Wild Guide.
An Amazon purchase link will be added here once the notebook is available.
IMPORTANT
This notebook is intended as a documentation, training, and quick-reference aid. It does not replace official agency patient care records, current training, clinical judgment, medical direction, local protocols, or applicable laws and regulations.
Providers should perform only those assessments, treatments, and procedures authorized by their training, scope of practice, agency, and medical direction.