PCR Instructions, Section 2

Remember to fill in the appropriate circles

Chief Complaint	Record the most important problem the patient is describing, or state the reason the unit was called. Use the patient's own words. Example: "My chest hurts; I can't breathe."
Subjective Assessment	From your patient interview, record additional information regarding the patient's Chief Complaint in the space provided.
Presenting Problem	Fill in the circle or circles that describe the patient's current problem(s). Mark all that apply; circle the primary problem. If necessary, describe any presenting problem in the Comment section. Do not record the patient's past medical history in this section.
Airway Obstruction	Complete or partial blockage of the route for the passage of air into the lungs.
Respiratory Arrest	When breathing stops completely.
Respiratory Distress	Difficulty in breathing.
Cardiac Related (Potential)	Signs and symptoms that may relate to, or indicate, a heart condition or disease.
Cardiac Arrest	When the heart stops beating and there is absence (disappearance) of a palpable carotid pulse.
Allergic Reaction	An abnormal or unexpected reaction to a substance such as a drug, an insect sting or bite, a food, dust, pollen, or chemical.
Syncope	A temporary loss of consciousness; fainting.
Stroke/CVA	A condition characterized by a sudden lessening or a loss of consciousness, sensation and/or voluntary movement. Cerebrovascular accident (CVA) is a medical problem and not a trauma-related problem.
General Illness/Malaise	A vague feeling of physical discomfort or uneasiness often occurring before or during an illness.
Gastro-Intestinal Distress	Complaints associated with the stomach and intestines such as nausea, vomiting, diarrhea, stomach pain, indigestion, and passage of blood in the stool.
Diabetic Related (Potential)	Signs and symptoms that are consistent with insulin shock or diabetic coma. Potential Insulin Shock: The patient is hypoglycemic with presenting signs of full, rapid pulse; normal breathing; dizziness; headache; fainting; seizures; disorientation; coma; normal blood pressure. Potential Diabetic Coma: Community marketplace The patient is hyperglycemic with presenting signs of sweet or fruity smelling breath; rapid, weak pulse; rapid, deep breathing; varying degrees of unresponsiveness up to coma; normal or slightly low blood pressure.
Pain	A sensation in which the patient states he is experiencing distress, discomfort, or suffering. Specify the type and location of pain on the line provided.
Unconscious/Unresponsive	When the Patient is comatose and does not react to verbal or painful stimuli.
Seizure	Involuntary contraction and relaxation of voluntary muscles (convulsions). These are signs, for example, that may be seen with a grand mal seizure.
Behavioral Disorder	an inappropriate mood or conduct exhibited by the patient.
Select Substance Abuse or Poisoning. Do not check both categories.
Substance Abuse (Potential)	An injection, ingestion, or inhalation of excessive amounts of any drug including alcohol. Overdose and suicide attempts using drugs and/or alcohol would fall into this category.
Poisoning (Accidental)	The injection, ingestion, exposure, inhalation, or absorption of any substance that will produce a harmful or injurious effect on the body. Substance abuse, overdose, or attempted suicides should not be recorded under this category.
Shock	is defined as: systolic BP is 90mmhg or less systolic BP above 90mmhg and signs of inadequate perfusion, such as: altered mental state (restlessness, inattention, confusion, agitation) tachycardia (pulse greater than 100) delayed capillary refill (greater than 2 seconds) pallor cold, clammy skin
Head Injury	Any obvious or suspected injury to the skull, brain, or facial structures.
Spinal Injury	Signs and symptoms consistent with injury to the vertebral column including fracture, dislocation, and disc injury (including compression), or suspicion of such injury based on the mechanism of injury.
Fracture/Dislocation	Suspected bone or joint injury such as a fracture or dislocations. Fracture: A break, crack, split, or crumbling of a bone. Dislocation: A temporary displacement of a bone out of its normal position in a joint.
Amputation	The traumatic removal or separation of a body part.
Other	Any presenting problem other than those listed in this section. Note the problem on the line provided and explain in detail in the Comment section.
Major Trauma	is present if the mechanism of injury or patient's physical findings meets any one of the following criteria. MECHANISM OF INJURY Death in the same passenger compartment. Fall more than 20 feet. Vehicle-pedestrian collision. Patient ejected from the vehicle. Vehicle collision greater than 20 MPH resulting in 12 inches of deformity to the vehicle. Vehicle rollover. Motorcycle crash. Vehicle vs. bicycle collision greater than 5 MPH. PHYSICAL FINDINGS Pulse less than 50/min or greater than 120/min. Systolic blood pressure of 90 mm Hg or less. Respiratory rate less than 10/min or greater than 28/min. Glasgow coma scale less than 14. Penetrating injuries of the trunk, head, neck, chest, abdomen or groin. Two or more proximal long bone fractures. Flail chest. Burns that involve 15% or more of the body surface or facial/airway burns. Combined system trauma that involves two or more body systems. Spinal cord injury or limb paralysis. Amputation (except digits).
Trauma - Blunt	A severe injury caused by a thick or dull-edged object. Since the damage occurs below the skin, there may not be a break in the skin.
Trauma - Penetrating	A severe injury with an entrance and/or exit wound. this includes penetrating wounds, perforating wounds, and impaled objects.
Soft Tissue Injury	An injury that involves skin, muscle, blood vessel, nerve, fatty tissue, or tissues that line or cover an organ. This injury is not severe enough to be classified as blunt trauma. Examples: contusions, abrasions, incisions, lacerations, avulsions.
Bleeding/Hemorrhage	Blood escaping from arteries or veins. The blood loss may be either internal, external, or both.
OB/GYN	Obstetrics (OB): Conditions resulting form the state of pregnancy. Gynecology (GYN): Conditions related to the female reproductive system.
Burns	An injury to the body surface and/or underlying tissue caused by overexposure to heat, chemicals, electricity, or radiation.
Environmental
Heat	A condition caused by exposure to excessively high temperatures. It may be characterized by heat cramps, heat exhaustion, or heat stroke.
Cold	A condition caused by exposure to excessively low temperatures. It may be characterized by frostnip, superficial frostbite, or freezing.
Hazardous Materials	Exposure to or an injury suspected to have been caused by hazardous materials such as solid, liquid or gaseous chemicals, or radioactive materials.
Obvious Death	Conforms to the commissioner of Health's statement of December 1, 1981, relative to CPR by EMTs. Obvious death includes decapitation or other similarly mortal injuries, or where rigor mortis, tissue decomposition or extreme dependent lividity is present (Policy Statement appended).