PCR Form

EMT Provider Name *

Incident Location

Date / Time of Dispatch

Date

Time

Name *

First

Last

PT D.O.B

Sex

• Male
• Female

Chief Complaint

Life / Limb Threats *

Pain Level

Selected Value: 1

Alert & Oriented

• A&O x 4
• Person
• Place
• Time
• Event

Glasgow Coma Scale

• 15
• Less than 15

Eye Opening4-Spontaneously3-To Speech2-To Pain1-None

Best Verbal Response5-Oriented4-Confused3-Inappropriate2-Incomprehensible1-Non

Best Motor Response6-Obeys Orders5-Localizes Pain4-Withdraw to Pain3-Flex to Pain2-Extends to Pain1-None

Vitals

Time *

Blood Pressure (BP) *

Pulse Rate *

SPo2 *

Glucose Level *

Respiration Rate *

Breathing *Choose OneNormalShallowRapidLabordedAbsent

Lung Sounds *Choose OneClearWheezesRalesRhonchiDiminishedAbsent

Location *LeftRightUpperLowerBi-Lateral

Skin Appearance *NormalPaleFlushedCyanotic

Skin Temperature *Choose OneHotCoolColdNormal

Skin Moisture *Choose OneDryMoistSweaty

Eyes *Choose OnePERLPinpointDilatedReactiveNon-Reactive

Non-PERL AssessmentChoose OneR>LL>R

Second set of vitals taken *

• Yes
• No

Time

Blood Pressure (BP)

Pulse Rate

SPo2

Glucose Level

Respiration Rate

Treatments Performed

Oxygen *Choose OneNo O2 GivenO2 Given

Device UsedChoose OneNCNRBBVMCPAP

Liters Per Minute (LPM)

Selected Value: 2

Pt outcomeChoose OneSameBetterWorse

Asprin *Choose OneNo Asprin GivenAsprin Given

Quantiy GivenChoose One12345

Pt OutcomeChoose OneWorseBetterSame

Oral Glucose *Choose OneNo Oral Glucose GivenOral Glucose Given

Tubes GivenChoose One1/3 Tube1/2 Tube3/4 Tube1 Tube1 1/2 Tubes2 Tubes

Pt OutcomeChoose OneSameWorseBetter

Nitroglycerin *Choose OneNo Nitro GivenNitro Given

Quanity GivenChoose One1/2 Tablet1 Tablet2 Tables

Pt OutcomeChoose OneBetterWorseSame

Epinephrin *Choose OneNo Epi GivenEpi Given

Amount GivenChoose One0.15 mg0.25 mg0.30 mg2 mg

Pt OutcomeChoose OneWorseSameBetter

Albuterol *Choose OneNo Albuterol GivenAlbuterol Given

Amount and number of treatments given

Pt OutcomeChoose OneBetterSameWorse

Naloxone *Choose OneNo Naloxone GivenNaloxone Given

RouteChoose OneIntraNasalIntermusclularOrally

Pt OutcomeChoose OneBetterWorseSame

Activated Charcoal *Choose OneNo Activated Charcoal GivenActivated Charcoal Given

Route

Pt OutcomeChoose OneWorseBetterSame

Patient History

Past Medical History *

• AMI
• CHF
• CVA
• COPD
• HTN
• Asthma
• Diabetes
• Seizures
• Cardiac
• Other
• No know history

Other Past Medical History

Allergies *

• NKA
• Yes-pt has allergies

List Allergies

Patient Medications *

Last Oral Intake *

Events Leading Up to Incident *

Trauma Assessment

Head/Neck *Choose OneChoice 3NormalAbnormal

Describe

Chest *Choose OneNormalAbnormal

Describe

Abdomen *Choose OneNormalAbnormal

Describe

Pelvis *Choose OneNormalAbnormal

Describe

Extremities *Choose OneNormalAbnormal

Describe

Narrative *

Patient Outcome

Is the patient under the age of 18? *Choose OneYesNo

Was ALS requested? *Choice 4NoYes

Reason for ALS...

Outcome of Event *

• Signed Refusal with Hospital Approval
• Released to another agency
• Transported to hospital
• Private Transport
• Pt Refused to Sign PCR

Outcome of Event (Minor)Choose OneTransferred careTransported to HospitalParent Signed Refusal

Did a responsible adult accompany minor to hospital?Choose OneYesNo

Responsible adult that accompied minor

Transported to which hospital

Transferred care to which agency/unit

Single Line Text

Paragraph Text

Name *

First

Last

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Report Completion Date / Time

Date

Time

Signature

Clear Signature

Single Line Text

Witness' Signature

Clear Signature

EMT Provider Signature *

Clear Signature

Submit

PCR Form

EMT Provider Name *

Incident Location

Date / Time of Dispatch

Date

Time

Name *

First

Last

PT D.O.B

Sex

• Male
• Female

Chief Complaint

Life / Limb Threats *

Pain Level

Selected Value: 1

Alert & Oriented

• A&O x 4
• Person
• Place
• Time
• Event

Glasgow Coma Scale

• 15
• Less than 15

Eye Opening4-Spontaneously3-To Speech2-To Pain1-None

Best Verbal Response5-Oriented4-Confused3-Inappropriate2-Incomprehensible1-Non

Best Motor Response6-Obeys Orders5-Localizes Pain4-Withdraw to Pain3-Flex to Pain2-Extends to Pain1-None

Vitals

Time *

Blood Pressure (BP) *

Pulse Rate *

SPo2 *

Glucose Level *

Respiration Rate *

Breathing *Choose OneNormalShallowRapidLabordedAbsent

Lung Sounds *Choose OneClearWheezesRalesRhonchiDiminishedAbsent

Location *LeftRightUpperLowerBi-Lateral

Skin Appearance *NormalPaleFlushedCyanotic

Skin Temperature *Choose OneHotCoolColdNormal

Skin Moisture *Choose OneDryMoistSweaty

Eyes *Choose OnePERLPinpointDilatedReactiveNon-Reactive

Non-PERL AssessmentChoose OneR>LL>R

Second set of vitals taken *

• Yes
• No

Time

Blood Pressure (BP)

Pulse Rate

SPo2

Glucose Level

Respiration Rate

Treatments Performed

Oxygen *Choose OneNo O2 GivenO2 Given

Device UsedChoose OneNCNRBBVMCPAP

Liters Per Minute (LPM)

Selected Value: 2

Pt outcomeChoose OneSameBetterWorse

Asprin *Choose OneNo Asprin GivenAsprin Given

Quantiy GivenChoose One12345

Pt OutcomeChoose OneWorseBetterSame

Oral Glucose *Choose OneNo Oral Glucose GivenOral Glucose Given

Tubes GivenChoose One1/3 Tube1/2 Tube3/4 Tube1 Tube1 1/2 Tubes2 Tubes

Pt OutcomeChoose OneSameWorseBetter

Nitroglycerin *Choose OneNo Nitro GivenNitro Given

Quanity GivenChoose One1/2 Tablet1 Tablet2 Tables

Pt OutcomeChoose OneBetterWorseSame

Epinephrin *Choose OneNo Epi GivenEpi Given

Amount GivenChoose One0.15 mg0.25 mg0.30 mg2 mg

Pt OutcomeChoose OneWorseSameBetter

Albuterol *Choose OneNo Albuterol GivenAlbuterol Given

Amount and number of treatments given

Pt OutcomeChoose OneBetterSameWorse

Naloxone *Choose OneNo Naloxone GivenNaloxone Given

RouteChoose OneIntraNasalIntermusclularOrally

Pt OutcomeChoose OneBetterWorseSame

Activated Charcoal *Choose OneNo Activated Charcoal GivenActivated Charcoal Given

Route

Pt OutcomeChoose OneWorseBetterSame

Patient History

Past Medical History *

• AMI
• CHF
• CVA
• COPD
• HTN
• Asthma
• Diabetes
• Seizures
• Cardiac
• Other
• No know history

Other Past Medical History

Allergies *

• NKA
• Yes-pt has allergies

List Allergies

Patient Medications *

Last Oral Intake *

Events Leading Up to Incident *

Trauma Assessment

Head/Neck *Choose OneChoice 3NormalAbnormal

Describe

Chest *Choose OneNormalAbnormal

Describe

Abdomen *Choose OneNormalAbnormal

Describe

Pelvis *Choose OneNormalAbnormal

Describe

Extremities *Choose OneNormalAbnormal

Describe

Narrative *

Patient Outcome

Is the patient under the age of 18? *Choose OneYesNo

Was ALS requested? *Choice 4NoYes

Reason for ALS...

Outcome of Event *

• Signed Refusal with Hospital Approval
• Released to another agency
• Transported to hospital
• Private Transport
• Pt Refused to Sign PCR

Outcome of Event (Minor)Choose OneTransferred careTransported to HospitalParent Signed Refusal

Did a responsible adult accompany minor to hospital?Choose OneYesNo

Responsible adult that accompied minor

Transported to which hospital

Transferred care to which agency/unit

Single Line Text

Paragraph Text

Name *

First

Last

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Report Completion Date / Time

Date

Time

Signature

Clear Signature

Single Line Text

Witness' Signature

Clear Signature

EMT Provider Signature *

Clear Signature

Submit

PCR Form

EMT Provider Name *

Incident Location

Date / Time of Dispatch

Date

Time

Name *

First

Last

PT D.O.B

Sex

• Male
• Female

Chief Complaint

Life / Limb Threats *

Pain Level

Selected Value: 1

Alert & Oriented

• A&O x 4
• Person
• Place
• Time
• Event

Glasgow Coma Scale

• 15
• Less than 15

Eye Opening4-Spontaneously3-To Speech2-To Pain1-None

Best Verbal Response5-Oriented4-Confused3-Inappropriate2-Incomprehensible1-Non

Best Motor Response6-Obeys Orders5-Localizes Pain4-Withdraw to Pain3-Flex to Pain2-Extends to Pain1-None

Vitals

Time *

Blood Pressure (BP) *

Pulse Rate *

SPo2 *

Glucose Level *

Respiration Rate *

Breathing *Choose OneNormalShallowRapidLabordedAbsent

Lung Sounds *Choose OneClearWheezesRalesRhonchiDiminishedAbsent

Location *LeftRightUpperLowerBi-Lateral

Skin Appearance *NormalPaleFlushedCyanotic

Skin Temperature *Choose OneHotCoolColdNormal

Skin Moisture *Choose OneDryMoistSweaty

Eyes *Choose OnePERLPinpointDilatedReactiveNon-Reactive

Non-PERL AssessmentChoose OneR>LL>R

Second set of vitals taken *

• Yes
• No

Time

Blood Pressure (BP)

Pulse Rate

SPo2

Glucose Level

Respiration Rate

Treatments Performed

Oxygen *Choose OneNo O2 GivenO2 Given

Device UsedChoose OneNCNRBBVMCPAP

Liters Per Minute (LPM)

Selected Value: 2

Pt outcomeChoose OneSameBetterWorse

Asprin *Choose OneNo Asprin GivenAsprin Given

Quantiy GivenChoose One12345

Pt OutcomeChoose OneWorseBetterSame

Oral Glucose *Choose OneNo Oral Glucose GivenOral Glucose Given

Tubes GivenChoose One1/3 Tube1/2 Tube3/4 Tube1 Tube1 1/2 Tubes2 Tubes

Pt OutcomeChoose OneSameWorseBetter

Nitroglycerin *Choose OneNo Nitro GivenNitro Given

Quanity GivenChoose One1/2 Tablet1 Tablet2 Tables

Pt OutcomeChoose OneBetterWorseSame

Epinephrin *Choose OneNo Epi GivenEpi Given

Amount GivenChoose One0.15 mg0.25 mg0.30 mg2 mg

Pt OutcomeChoose OneWorseSameBetter

Albuterol *Choose OneNo Albuterol GivenAlbuterol Given

Amount and number of treatments given

Pt OutcomeChoose OneBetterSameWorse

Naloxone *Choose OneNo Naloxone GivenNaloxone Given

RouteChoose OneIntraNasalIntermusclularOrally

Pt OutcomeChoose OneBetterWorseSame

Activated Charcoal *Choose OneNo Activated Charcoal GivenActivated Charcoal Given

Route

Pt OutcomeChoose OneWorseBetterSame

Patient History

Past Medical History *

• AMI
• CHF
• CVA
• COPD
• HTN
• Asthma
• Diabetes
• Seizures
• Cardiac
• Other
• No know history

Other Past Medical History

Allergies *

• NKA
• Yes-pt has allergies

List Allergies

Patient Medications *

Last Oral Intake *

Events Leading Up to Incident *

Trauma Assessment

Head/Neck *Choose OneChoice 3NormalAbnormal

Describe

Chest *Choose OneNormalAbnormal

Describe

Abdomen *Choose OneNormalAbnormal

Describe

Pelvis *Choose OneNormalAbnormal

Describe

Extremities *Choose OneNormalAbnormal

Describe

Narrative *

Patient Outcome

Is the patient under the age of 18? *Choose OneYesNo

Was ALS requested? *Choice 4NoYes

Reason for ALS...

Outcome of Event *

• Signed Refusal with Hospital Approval
• Released to another agency
• Transported to hospital
• Private Transport
• Pt Refused to Sign PCR

Outcome of Event (Minor)Choose OneTransferred careTransported to HospitalParent Signed Refusal

Did a responsible adult accompany minor to hospital?Choose OneYesNo

Responsible adult that accompied minor

Transported to which hospital

Transferred care to which agency/unit

Single Line Text

Paragraph Text

Name *

First

Last

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Report Completion Date / Time

Date

Time

Signature

Clear Signature

Single Line Text

Witness' Signature

Clear Signature

EMT Provider Signature *

Clear Signature

Submit

Contact

For any inquiries please email or call

info@firstfiveems.com


773-741-3042

Facebook-f Instagram Youtube Twitter