PCR Instructions, Section 4

Remember to fill in the appropriate circle.

Treatment Given	Fill in the circles that describe the treatments given by your agency. Mark all that apply.
Moved to Ambulance on Stretcher/Backboard	Fill in the circle if the patient was moved to the ambulance on a stretcher and/or a backboard.
Moved to Ambulance on stair chair	Fill in the circle if the patient was moved to the ambulance on a stair chair.
Walked to Ambulance	Fill in the circle if the patient walked to the ambulance.
Airway Cleared	Fill in the circle if the patient's airway was cleared.
Oral/Nasal Airway	Fill in the circle if an oropharyngeal or nasal airway was used.
EOA/EGTA	Fill in the circle only if the placement of an esophageal obturator airway or an esophageal gastric tube airway was successful. Circle either EOA or EGTA. If the attempt was unsuccessful, explain in the Comment section.
Endotracheal Tube (E/T)	Fill in the circle if the placement of an endotracheal tube was successful. If the attempt was unsuccessful, explain in the Comment section.
Oxygen Administered	Fill in the circle if oxygen was given. Record the number of liters per minute and the appliance(s) used. Examples: Oxygen Administered @ 12 LPM. Method 100% non-rebreather; Oxygen Administered @4 LPM, Method 24% Venturi.
Suction Used	Fill in the circle if the patient was suctioned.
Artificial Ventilation	Fill in the circle if the patient was artificially ventilated and record method. Examples: mask to mouth, positive pressure.
CPR in progress on arrival by:	Fill in the circle if cardiopulmonary resuscitation (CPR) was initiated prior to the arrival of responding emergency personnel. (NOTE: If the above is checked, check all the following that apply.
Citizen	Fill in this circle if CPR was initiated by an individual who was not part of emergency services personnel (EMS, fire, or police) who responded in an official capacity.
PD/FD/Other       First Responder	Fill in this circle if CPR was initiated by personnel from the Police Department or Fire Department or a Certified First Responder who responded in an official capacity.
Other	Fill in this circle if CPR was initiated by a physician, nurse, or other EMS personnel (i.e., CFR or EMT who did not respond in an official capacity).
CPR Started	Fill in this circle if the patient was given CPR by anyone (bystander, CFRs, your agency, etc.)
Time From Arrest Until CPR	Enter the best approximation of the patient's down time prior to CPR being administered by anyone. Only enter this time if you have a reliable source of information regarding the patient's down time. If the time is unknown, leave the boxes blank.
EKG Monitored	Fill in the circle if an electrocardiogram (EKG/ECG) was performed and attach section of the tracing to the agency (white) and Hospital (pink) copies of the PCR. Indicated the interpretation of each significant tracing in the space provided.
Defibrillation/ Cardioversion	Fill in the circle if the patient was defibrillated or cardioverted. Indicate the number of time and whether the equipment used was manual or semi-automatic.
Medication Administered	Fill in the circle if your crew administered any medication (s). List all medications including time, dosage, and route on a Continuation Form.
IV Established	Fill in the circle if an intravenous line was established or attempted. Do not mark this section if the IV was started by hospital personnel prior to an Interfacility Transfer (note in Comment section). Indicate the IV fluid (normal saline, D5W, lactated Ringers) administered, and the catheter gauge used. For additional IVs administered, use a Continuation Form.
MAST Inflated	Fill in the circle only if MAST were inflated; enter the time MAST were inflated. (NOTE: Only enter a time if MAST is inflated. Do not enter a time if applied but not inflated.)
Bleeding/Hemorrhage Controlled	Fill in the circle and enter the method used to control bleeding/hemorrhage.
Spinal Immobilization	Fill in the circle if spinal column was immobilized. Circle "neck" or "back" or both to indicate the area(s) immobilized.
Limb Immobilized	Fill in the circle if arms or legs were immobilized. Also fill in the circle(s) to indicate the method (fixation and/or traction).
(Heat) or (Cold) Applied	Fill in the circle if either heat or cold applications were used. Circle either "heat" or "cold" to note the appropriate application.
Vomiting Induced	Fill in the circle if vomiting was induced. Note the time and method used. Use military time; to calculate military time, see General Instructions.
Restraints Applied	Fill in this circle if restraint devices or methods were used to prevent the patient from injuring him/herself or others. Indicate the type of restraints used. Restraints applied by other agencies (e.g., police) should be noted in the Comment Section.
Baby Delivered	Fill in the circle if a baby was delivered. Note the time of delivery, the county in which the baby was born, if the baby was born alive or stillborn and whether the baby was male or female. Note the time of birth in military time; to calculate military time, see General Instructions. Complete a separate PCR form for each infant delivered.
Transport
Trendelenburg      Position	Fill in the circle if the patient was transported in the Trendelenburg position.
left lateral      recumbent position	Fill in the circle if the patient was transported in the left lateral recumbent position.
with head elevated	Fill in the circle if the patient was transported with their head elevated.
Other	Fill in the circle if the treatment or care given has not been noted above. Enter the treatment or care given on the line provided. Use the Comment Section if additional space is needed.
Disposition	If your unit transported the patient to a hospital, nursing home, or other medical facility (e.g., doctor's office, clinic, health center), enter the name of the facility. Enter "residence" if the patient was taken home. When these do not apply, enter the phrase from the "Disposition Code" list below that best describes the outcome of the call. Non-hospital disposition codes are listed on the back of the PCR form.
Disposition Code	Enter the code number from the list below that corresponds to the disposition entered. Note that each hospital has an individual code number listed on the PCR Disposition Code List (PDF File; also available from the Depatment of Health). Nontransporting services should only use codes 004 through 010. Code   Disposition 001     Nursing Home 002     Other Medical Facility 003     Residence 004     Treated by this Unit and Transported by Another 005     Refused Medical Aid or Transport 006     Call Canceled En Route 007     Standby Only 008     Gone on Arrival (Patient removed prior to arrival) 009     Unfounded (False Alarm or no patient found) 010     Other
Continuation Form Used	Place an X over the word YES if a Continuation Form was used on this call.
Crew	Enter the names of the crew members. If there are more than four members on the call, list the additional names in the Comment Section. The crew member in charge of the call should be entered in the first box; the driver's name must be entered in the second box.      When the crew member is certified at any level, fill in the circle which indicates his/her highest level of certification and enter the six-digit NYS certification number in the space provided. If the crew member is not New York State certified enter the person's name only, do not enter any numbers.