Initial Assessment and Treatments Secondary Assessment Patient info and Signature Order Number Click here to download a printable PCR Form Instructions: DO NOT USE THE BACK BUTTON You may move between sections. Once submitted this form cannot be revised or edited. Incident Location State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Incident Date Incident Time Patient First Name Patient Last Name Patients Job Title Patient Age Chief Complaint Pain Level 1-10 1 Alert & Oriented A&O X 4 Person Place Time Event Glasgow Coma Scale Open the Glasgow Calculator Vitals 1st set of vitals 1st set of vitals Time BP Pulse Respiration SPO2 Glucose Level Temperature + Route 2nd set of vitals 2nd set of vitals 3rd set of vitals Time BP Pulse Respiration SPO2 Glucose Level Temperature + Route Additional Vitals and Information Treatments Treatments Given/Performed Did you give any OTC's? YesNo Over the Counter Medications Ibuprofen Benadryl Tylenol Clairton Dayquil Sudafed Dramamine Antacid tablets Anti-Diarrheal Emergen-C Midol Cough Drops B-12 tablets Insta-Glucose Electrolyte tabs Baby Aspirin 81mg OTC notes Did you use Oxygen? YesNo Oxygen NC NRB BVM Suction L/min 2 LPM 4 LPM 6 LPM 10 LPM 15 LPM Oxygen Notes Is this a CPR? YesNo Witnessed Arrest? YesNo Bystander CPR? YesNo Was the Pt Shocked before your arrival? YesNo Time CPR Started Was an AED used? YesNo By Whom Who's AED Number of Shocks: CPR notes Did you give any ALS medicines? YesNo Advanced Medicines Med 1 Name Dose Route PO IM IV IN Time Administered NSM Tag # Administration notes Med 2 Name Dose Route PO IM IV IN Time Administered NSM Tag # Administration notes Med 3 Name Dose Route PO IM IV IN Time Administered NSM Tag # Administration notes Med 4 Name Dose Route PO IM IV IN Time Administered NSM Tag # Administration notes Med 5 Name Dose Route PO IM IV IN Time Administered NSM Tag # Administration notes Additional Advanced Meds and Treatments Narrative Patient History Past Medical History AMI CHF Diabetes CVA HTN Seizures COPD Asthma Cardiac OTHER: PMH OTHER Allergies Patient Medications Last Oral Intake Events Leading to illness or injury Secondary Assessment Breathing NORMAL Shallow Retractions Labored Absent Rapid Lungs Sounds CLEAR Wheezes Rales Rhonchi Diminished Absent Lungs Sound Locations Left Right Upper Lower Bilateral Skin Appearance NORMAL Pale Flushed Cyanotic Skin Temp NORMAL Cold Cool Warm Hot Skin Moisture NORMAL Dry Moist Circulation: Cap refil NORMAL Delayed Eyes PERL Pinpoint Diolated Reactive NonReactive Non-Perl Assessment R>L L>R Non-Perl in MM Head/Neck Assessment Chest Assessment Including Shoulder and back Abdomen Assessment Pelvis Assessment Extremity Assessment Medic Information and Affirmation Medic Affirmation I affirm that this information is correct and accurate to the best of my ability Privacy Policy * Medic's Name and Title * Report Date * Patient Information and Consent Patient Name Patient Address Patient Phone number Patient Email Sex MaleFemale Date of Birth Is the patient a minor? YesNo Parent/Guardian Name Relation to Patient Guardian Phone Number Patient Outcome Released at Scene Released at Scene Released to higher or equal care Refusing Against Medical Advice (AMA) Transported by: Suggested Follow up Instructions Consent By 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. See Privacy Policy * Patient/Guardian Signature * Please print your name Last 4 of your Social Security Number * Enter 0000 if patient has no SS#