The narrative is the part of the PCR that nurses, doctors, lawyers, and reviewers read first. Everything else in the report supports it. Write it accordingly.

The Narrative tab of a CloudPCR record showing the Patient Care Narrative text area and the Generate Narrative button in the section header.

Where it lives

The narrative is its own tab — Narrative. It is a single large text area labeled Patient Care Narrative. What you type auto-saves as you type — there is no Save button to press.

A useful structure

CloudPCR does not enforce a structure. Most providers use one of two:

CHART

  • Chief complaint — what the patient said is wrong.
  • History of present illness — when it started, what they were doing, what they tried.
  • Assessment — what you found.
  • Rx / treatment — what you did.
  • Transport — destination, mode, and condition on arrival.

SOAP

  • Subjective — what the patient told you.
  • Objective — what you measured and saw.
  • Assessment — your impression.
  • Plan — what you did and where you went.

What makes a good narrative

  • Stick to what you saw and what the patient told you.
  • Quote the patient when their words matter.
  • Document the pertinent negatives — "no chest pain, no shortness of breath, no diaphoresis."
  • Reference the treatments you gave and how the patient responded.
  • Document the handoff — who took report and where.

An example

"66 y/o male with hx of HTN and CAD c/o substernal CP 8/10 that started 30 minutes prior to arrival while watching TV. Pain radiates to L arm, associated with diaphoresis and SOB. Patient denies recent surgery, anticoagulants, or sildenafil use. On exam: alert and oriented, skin pale and diaphoretic, breath sounds clear bilaterally, abdomen soft. 12-lead ECG: ST elevation in II, III, aVF — concerning for inferior STEMI. STEMI alert called to [receiving hospital] at 10:14. ASA 324 mg PO chewed at 10:08. NTG 0.4 mg SL at 10:10 with pain reduction from 8/10 to 5/10. IV established 18g L AC, NS at TKO. Transported emergent to [receiving hospital]. Pain 3/10 on arrival. Report given to RN [name]."

Important: Never copy and paste from another patient's PCR. Reviewers can tell, the audit log shows it, and on a bad day in court it can look like fraud.