PCR Important Links: Click here to download a printable PCR Click here for the PCR Addendum FormForm Instructions: DO NOT USE THE BACK BUTTON DO NOT REFRESH YOUR BROWSER Once submitted this form cannot be revised or edited. Use the Addendum form if necessary. Incident Location(Required)Incident State(Required)Incident InformationIncident Date(Required) MM slash DD slash YYYY Incident Time(Required)Patient First Name(Required)Patient Last Name(Required)Patients Job TitlePatient Age(Required)Date of Birth MM slash DD slash YYYY Gender(Required) Male Female Email(Required) Leave this email as-is if Pt has no email or declines to provide one.Is the patient a minor? No Yes Parent/Guardian NameRelation to PatientGuardian PhoneChief Complaint and Initial AssessmentChief ComplaintInclude MOIPain LevelN/A12345678910Alert and Oriented(Required) A&O x 4 Person Place Time Event Glasgow Coma ScaleEyes Open 4-Spontaneously 3-To Speech 2-To Pain 1-None Best Motor Response 6-Obeys Orders 5-Localizes Pain 4-Withdraw to Pain 3-Flex to Pain 2-Extension to Pain 1-None Best Verbal Response 5-Oriented 4-Confused 3-Inappropriate 2-Incomprehensible 1-None Mild: GCS 13-15 | Moderate: GCS 9-12 | Severe: GCS 8 or lessVitalsFirst Set of Vitals Hours : Minutes AM PM AM/PM B/P - 1Pulse - 1Respirations - 1SPO2 - 1Temperature + Route - 1Glucose -1Additional Vitals and InformationInput a Second Set of Vitals Second Set of Vitals (Click here) Second Set of Vitals Hours : Minutes AM PM AM/PM B/P - 2Pulse - 2Respirations - 2SPO2 - 2Temperature + Route - 2Glucose -2Additional Vitals and Information - 2Input a Third Set of Vitals Third Set of Vitals (Click here) Third Set of Vitals Hours : Minutes AM PM AM/PM B/P - 3Pulse - 3Respirations - 3SPO2 - 3Temperature + Route - 3Glucose -3Additional Vitals and Information - 3Input Four or more Sets of Vitals 4 or more Set of Vitals (Click here) Additional Vitals and Information - 4+Type in all additional vitals line by lineTreatmentsTreatments Performed/GivenDid you give any OTC's No Yes Over-the-counter medication givenDid you give Oxygen? No Yes Oxygen NotesRoute, LPM, etc.Is this a CPR? No Yes CPR NotesWitnessed? Bystander CPR? AED? Time CPR started? etc.Did you give any ALS drugs? No Yes ALS Drug NotesInclude: Med name, Dose, route, time admin, notesPatient HistoryPast Medical History AMI CHF Diabetes CVA HTN Seizures COPD Asthma Cardiac OTHER Other Past HistoryAllergies NKDA Yes (please list) List of AllergiesPatient MedicationsName, dose, etc.Last Oral IntakeSecondary AssessmentBreathing Normal Shallow Rapid Retractions Labored Absent Lung Sounds CLEAR Wheezes Rales Rhonchi Diminished Absent Skin Appearance NORMAL Pale Flushed Cyanotic Skin Temp NORMAL Cold Cool Warm Hot Skin Moisture NORMAL Dry Moist Cap Refil NORMAL Delayed Eyes PERL Pinpoint Dilated Reactive Non-Reactive Eyes Non-Perl NotesHead/Neck AssessmentChest, Shoulder and Back AssessmentAbdomen AssessmentPelvis AssessmentExtremity AssessmentNarrativeMedic Narration(Required)Patient DispositionPatient Outcome(Required) Released at Scene Released to higher or equal care Refusing against Medical Advice (AMA) EMS Refusal of Care I am refusing medical assessment. I am refusing medical treatment I am refusing medical transportation I have received medical assessment and treatment, but decline medical transportation. I am insisting on medical transport to a hospital other than EMS personnel recommend. Transported by / Released to:Medic DetailsMedic Affirmation(Required) I affirm to the accuracy of this report.I affirm that this information is correct and accurate to the best of my ability.Medic Name and Title(Required)Report Date(Required) MM slash DD slash YYYY Release signaturePatient Consent(Required) Non-Liability AcknowledgementBy clicking this box I understand that the EMS personnel are not physicians and are not qualified or authorized to make a diagnosis and that their care is not a substitute for that of a physician. I recognize that I may have a serious injury or illness which could get worse without medical attention even though I (or the patient on whose behalf I legally sign this document) may feel fine at the present time. I will not hold NSM liable for any treatments or non-treatments.Patient/Guardian Typed Signature(Required)Last 4 of your Social Security Number(Required)Enter 0000 if Patient has no SS#