PCR Instructions, Section 4

Treatment Given	Place an X in the boxes that describe the treatments given by your agency. Mark all that apply.
Moved to Ambulance on Stretcher/Backboard	Place an X in the box if the patient was moved to the ambulance on a stretcher and/or a backboard.
Moved to Ambulance on stair chair	Place an X in the box if the patient was moved to the ambulance on a stair chair.
Walked to Ambulance	Place an X in the box if the patient walked to the ambulance.
Airway Cleared	Place an X in the box if the patient's airway was cleared.
Oral/Nasal Airway	Place an X in the box if an oropharyngeal or nasal airway was used.
EOA/EGTA	Place an X in the box 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)	Place an X in the box if the placement of an endotracheal tube was successful. If the attempt was unsuccessful, explain in the Comment section.
Oxygen Administered	Place an X in the box 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	Place an X in the box if the patient was suctioned.
Artificial Ventilation	Place anX in the box if the patient was artificially ventilated and record method. Examples: mask to mouth, positive pressure.
CPR in progress on arrival by:	Place an X in the box 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	Place an X in this box 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	Place an X in this box 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	Place an X in this box 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	Place an X in this box 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	Place an X in the box 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	Place an X in the box if the patient was defibrillated or cardioverted. Indicate the number of time and whether the equipment used was manual or semi-automatic.
Medication Administered	Place an X in the box if your crew administered any medication (s). List all medications including time, dosage, and route on a Continuation Form.
IV Established	Place an X in the box 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	Place an X in the box 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	Place an X in the box and enter the method used to control bleeding/hemorrhage.
Spinal Immobilization	Place an X in the box if spinal column was immobilized. Circle "neck" or "back" or both to indicate the area(s) immobilized.
Limb Immobilized	Place an X in the box if arms or legs were immobilized. Also place an X in the box(es) to indicate the method (fixation and/or traction).
(Heat) or (Cold) Applied	Place an X in the box if either heat or cold applications were used. Circle either "heat" or "cold" to note the appropriate application.
Vomiting Induced	Place an X in the box if vomiting was induced. Note the time and method used. Use military time; to calculate military time, see General Instructions.
Restraints Applied	Place an X in this box 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	Place an X in the box 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	Place an X in the box if the patient was transported in the Trendelenburg position.
left lateral      recumbent position	Place an X in the box if the patient was transported in the left lateral recumbent position.
with head elevated	Place an X in the box if the patient was transported with their head elevated.
Other	Place an X in the box 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 (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, place an X in the box 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.