The Prehospital Care Report (PCR) was developed by a committee of Emergency Medical Services providers and administrators assembled from across the State of New York to establish a statewide emergency medical services data system. The PCR is a form to be used for documentation of patient care by all prehospital care providers including Certified First Responders, Emergency Medical Technicians, and Advanced Emergency Medical Technicians. The PCR serves as a medical record, a legal document, and an essential research record.

All aspects of patient care referred to on the form are in accordance with the training certified through the EMS Program of the New York State Department of Health. This document covers all phases from initial patient contact through treatment and disposition of the patient. This report assists the prehospital care provider in completing a thorough patient assessment and rendering proper aid.

The Prehospital Care Report is a medical record and becomes a part of the patient's permanent hospital record. This form provides the emergency department with essential information regarding the incident and the assessment and treatment of the patient prior to arrival at the hospital. The PCR is of value to the physicians and nurses in determining the patient's condition and appropriate treatment.

The Prehospital Care Report is a legal document. This document becomes the proof by which the prehospital care provider can substantiate all that was done for the patient and that the provider acted within the scope of his/her training. The PCR must be accurate, complete, legible, and free of nonprofessional information. Details that may seem insignificant at the time may be extremely important in a legal review years later. If details are not stated immediately, they cannot be added after submission of the PCR. In purely legalistic terms, if it doesn't appear on the PCR, it will probably be considered that the action was not taken. "If you didn't write it down, you didn't do it."

The Prehospital Care Report is a standardized record that is used for data collection and research purposes. The information assembled from these records is extremely important to EMS providers and local, regional and state agencies in generating support for emergency medical services. A comprehensive data base is an essential step in the development of a strong statewide EMS system.

NEW YORK STATE'S
	EMERGENCY MEDICAL SERVICES
PEOPLE WHO CARE

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GENERAL INSTRUCTIONS

The PCR is a three-part document printed on NCR paper. Each form is bonded at the top. Care must be taken that what is written on one PCR set does not come through on the set below (an aluminum form-holder clipboard is recommended). It is important that firm pressure with a ballpoint pen be used. Be as neat, complete and accurate as possible when completing this form. If a section does not apply to a particular call, leave it blank. Do NOT write NA or draw lines across sections of the form. It is important for the crew members to review the document before it is submitted. If an error is made prior to the PCR being submitted, enter the correct information on a second PCR and destroy all copies of the first form.

DISTRIBUTION OF COPIES

The distribution of the PCR is as follows:
White copy online dating with Slavic who searching for love is retained by the agency.
Yellow copy is used for data collection, and agencies should follow procedures for collection of these records. This copy is the only acceptable form for the data program, because it contains the keypunch codes.
Pink copy becomes part of the medical record and therefore must be left at the hospital.

WHEN TO USE A PCR

Complete a PCR for every patient and every call. The PCR is used to substantiate all patient assessment and care provided, and documents all calls including canceled calls, standby calls, refused medical aid calls, walk-ins, etc. The call outcome is recorded in the Disposition section of the form (see Disposition Codes). A PCR should not be completed when the unit is being used for administrative purposes such as driver training or vehicle maintenance.

A separate PCR should be completed for each patient. When a mother and newborn infant are transported together, or a baby is delivered en route, separate PCRs should be completed for the mother and each infant.

A separate PCR should be completed for each patient transport. A PCR should be completed whenever a patient is delivered to a destination such as a hospital, nursing home, or doctor's office. If the same patient is then transported to another facility/destination or returned to the original call location, a second PCR should be completed. For example, when a patient is taken to and from a hospital for diagnostic tests or for therapeutic purposes, two PCRs should be completed. Or, when a critical patient is taken to one hospital and then transferred to another hospital, a separate PCR should be completed for each leg of the trip.

TIERED RESPONSES

When more than one agency responds to the scene, each service should complete a separate PCR. Each PCR should reflect only the actions taken by that crew.

When a fly car arrives at the scene prior to an ambulance from the same agency, two PCRs should be completed.

When patient assessment and/or treatment is provided by a first responder agency, fly car, or other nontransporting service, a PCR should be completed and the Disposition Code 004, "treated by this unit and transported by another," should be entered on the form. The hospital (pink) copy should be given to the transporting ambulance to accompany the patient to the hospital.

In the best interest of patient care, the first responder PCR (pink hospital copy) should accompany the patient even though in some instances the PCR may not have been totally completed at the time the transporting ambulance is ready to leave the scene. Patient transport should not be delayed to complete the first responders' PCR.

MILITARY TIME

Military time must be used for all time entries on the PCR. Military time can be easily calculated by adding 12 hours to any time after noon and before midnight. All military times are in four-digit form.

Examples: Military time
12:00 PM (noon)	1200
3:00 PM	1500
12:00 AM (midnight)	2400
12:05 AM	0005

SHADED AREAS OF THE PCR

Areas of the PCR containing patient information that should be relayed to the hospital have been shaded on the agency (white) copy of the form for easy reference.

THE BACK OF THE FORM

Non-Hospital Disposition Codes: A listing of codes used other than state hospital codes.

Hospital Receiving Agent: This section is available for those agencies required to obtain a signature from the hospital personnel receiving the patient. When used, open the form so that the signature is on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy).

Refusal of Treatment/Transportation Release: This section is provided for legal protection when a patient refuses treatment or transportation by your agency. When used, open the form* so that all entries are on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy). Circle "treatment" and/or "transport to a hospital" and have the patient and the witness sign on the lines provided.

The Rule of Nines: Figures are for your reference in assessing burn severity.

Glasgow Coma Scale and Trauma Score: Guides are for your reference in completing the Vital Signs section of the PCR.

ICD Diagnostic Code: for Hospital use only.

Insurance Data: Enter the insurance information that your agency requires.

*Any time you write on the back of one of the pages, you must open the form so that what is written does not destroy the data on the front of the page use free dating online Asian now .