DETAILED PCR INSTRUCTIONS

PCR Version 5: Version 5 contains all of the information that was on version 4, however, the top section of the form is laid out differently. In addition, there are no more check-boxes. Instead, circles are used. When you mark a circle, please fill it in completely, do not just check it. This is so the form can be scanned.

Serial # 5-0000000	Located in the upper center of PCR form: this number is to identify each call. Be careful when separating the copies that you do not tear this number off. If this happens you should tape the torn pieces together immediately. The form will not be accepted without this number.
Date of Call	Enter the date the call is received. If a unit is reserved ahead of time for a transport, enter the date the unit responds. Numbers less than 10 are to be listed as two digits. Example: January 2, 2001 (01:02:01). NOTE: The record is dropped from all data reports if the date is omitted; this is a required area.
Run #	Enter the number assigned by your dispatcher or agency.
Agency Code	Enter the number that is assigned to your agency by the Emergency Medical Services Program of the New York State Department of Health. This is a required area.
Vehicle ID	Enter the identification number of the vehicle that responds to the call. This is the number assigned by your agency.
Agency Name	Enter the official name of your agency or service.

Dispatch Information	Enter any additional dispatch information provided to your agency or service. (Examples: MVA, unconscious patient, gunshot wound).

Call Location	Enter the address of the incident scene to which you were dispatched.

Location Code	Enter the four-digit municipality code, from the New York State Gazeteer, for the municipality in which the patient is located at the time of your response. This is a required area. Location codes for the Southern Tier and the surrounding area are available at Location Codes
PATIENT INFORMATION

Patient Name	Enter the name of the patient - First Name, Last Name, one letter per box. This is a required area. If the name is unknown, write "unknown;" add important identifiers in the "Comments" section.
Patient Address	Enter the patient's address. Be as complete as possible. If the address is unknown, write "unknown."
Phone	Enter the patient's telephone number.
City, State, Zip	Community marketplace Enter the patient's city, state and Zip Code; include the Zip+4 if known.
Age, DOB, Sex, SS#	Enter the patient's age. If the patient is less than one year old, write the number of days, weeks or months, followed by the appropriate letter (e.g., 21D, 5W, 9M). Write in the patient's date of birth; April 8, 1987 would be entered as 04 08 1987. Fill in the appropriate circle to indicate the patient's sex. Write in the patient's Social Security number. This is a required area. If you cannot get the SS#, fill in the spaces with 0's.
Mileage	Enter the mileage information required by your agency. Indicate the mileage on the responding vehicle's odometer at the beginning of the run and at the end of the run. Subtract the "beginning" reading from the "end" reading and enter the "total" mileage.
Location Type	Fill in the appropriate circle indicating the location where the patent was initially found. (Fill in ONLY one circle). Residence: Private homes, multiple occupancies such as apartments, dormitories, etc. (Note: May not necessarily be the patient's own residence). Health: A facility where medical care is routinely provided. (Examples include: hospital, nursing home, doctor's office, health clinic, emergicare clinic, infirmary). Farm: National Safety Council Definition: A rural place from which $1,000 or more of agricultural products were sold, or normally would have been sold. (Examples: dairy farms, fields where crops are grown, chicken farms, tree farms; includes barns as well as fields). Industrial: A place where a product is manufactured or stored. (Examples: warehouses, manufacturing plants, etc.). Other Work: A place of work other than an industrial facility. (Example: Offices). Recreational: National Safety Council Definition: Recreational places are those organized for recreation or sport but excluding homes and industrial places. (Examples: gymnasium, tennis court, bike or jogging path, basketball courts).[Note: this is listed as "Residence" on the current copies of PCR 5.] Roadway: A place that is designated as a thoroughfare for motor vehicles, to include passenger vehicles, trucks and motorcycles. Not a private residence driveway. (Examples: interstates, town or village roads, county roads, streets). Other: Any place which has not been defined by any of the other call locations in this section.
Call Times	Only enter military tmes in this section. To calculate military time, see General Instructions.
Call Rec'd	Enter the time the service/agency receives the call. If a unit was reserved ahead of time for a transport, record the time when the vehicle responds. In that case, the call received time and the enroute time will be the same.
Arrived At Scene	Enter the time the unit arrives at the incident location. If the incident is within a structure, the time the emergency vehicle arrives at the structure should be entered.
From Scene	Enter the time of departure from the scene.
At Destin	Enter the time the unit arrives at the destination. The destination (hospital, nursing home, residence, etc.) is where the patient is unloaded. If the unit does not transport, leave blank.
In Service	Enter the time when the unit is available to receive another call. If your county or region requires the research (yellow) copy to be handed in at the hospital, estimate and enter in-service time.
In Quarters	Enter the time the unit is back in the station where it is regularly housed. If the unit is dispatched to another call before returning to quarters, then this time should be left blank.
Call Received As	Fill in the circle that indicates how the call was received from the dispatcher. Indicate whether the unit responding was dispatched as an emergency, a non-emergency, or a standby. NOTE: The PCR will automatically be entered as an emergency call if not marked otherwise. Emergency: Fill in this circle when a call is dispatched as an emergency or a potential emergency even though it may not turn out to be an emergency. This includes any emergency or critical care transfers. Non-Emergency: Fill in this circle for routine calls such as a non-urgent transport from home to hospital, a transport from hospital to home, or a non-urgent call to assist a patient at home. This includes any non-urgent transfers. Stand-by: Fill in this circle when your unit is dispatched but no patient is treated such as when covering a football game, standing by at a fire, or providing mutual aid at a neighboring station. If an incident occurs during a standby such as an injured football player, a separate PCR should be completed and the appropriate Call Type (emergency, non-emergency) marked.
Physician	Enter the name of the patient's personal physician.
Care in Progress on Arrival	Fill in the appropriate circle to indicate the type of care, if any, the patient received prior to your arrival. Indicate what was done for the patient in the comment section.

	None: the patient is not receiving any care. Citizen: care is being administered by a person who is not certified at any level of EMS. PD/FD/Other First Responder: care is being administered by a member of the Police Department, Fire Department, or another certified as a First Responder (may be off-duty). Other EMS: patient is being cared for by physician, nurse, EMT or paramedic (may be off-duty). PAD Used: Fill in this circle to indicate if Public Access Defibrillation was used.
Mechanism of Injury:	Fill in the appropriate circle, mark all that apply.

MVA (check seat belt used)	Fill in this circle if the patient was in a motor vehicle at the time of the accident (this includes motorcycles). If in doubt, check to see if the police agency investigating completes an MV-104A form. (If this circle is filled, then the "Seatbelt used?" section must be completed).
Struck by Vehicle	Fill in this circle if the patient was struck by a vehicle (including a motorcycle). The patent could be a pedestrian or riding on a non-motorized vehicle such as a bicycle. If in doubt, check to see if the police agency investigating completes an MV-104 form.
Fall of ____ feet	Fill in this circle if the patient fell from some height. (If this circle is filled, place a number in the section to indicate the approximate number of feet of the fall).
Unarmed Assault	Fill in this circle if the patient was assaulted (harmed by another person) but no weapon such as gun,knife, etc., was used.
GSW (Gun Shot Wound)	Fill in this circle if the patient was injured by ballistics from a rifle, handgun or shotgun. This circle should be filled whether the wound was intentional or accidental.
Knife	Fill in this circle if the patient was harmed by a knife or knife-like object (i.e., scissors, screwdriver).
Machinery	Fill in this circle if the patient's injury was related to use of any type of machinery (i.e., farm or industrial equipment).
____________	Fill in this circle if the mechanism of injury is not among the choices listed on the PCR; fill in the cause of injury.
Extrication required __________ minutes	Fill this circle if the patient had to be extricated. (Note: this does not just apply to motor vehicles but any situation where extraordinary measures and/or equipment must be used to disentangle a patient for treatment and/or transport). (NOTE: If this circle is marked, then the details of the situation that required the patent to be extricated should be placed the comment section). The number of minutes required to extricate the patient should be placed in the space provided. The number of minutes to extricate a victim is determined from the time "at scene" till the patient is free to be removed from the situation and transported.
Seat Belt Used?

	Fill in the appropriate circle to indicate if the patient being reported on the PCR was using safety equipment such as a lap belt, shoulder harness, 3 point harness, or child restraint device. This may be determined by observation of the crew, or as reported by the police, or stated by the patient, or reported by other observers. Fill in the appropriate circle. Do not complete this section for pedestrians, bicycle riders, or motorcycle riders involved in the MVA.