New York State Pcr

Prehospital Care Report IinIiI ~

1J. 't

DATE OF CALL

Name

924451 0

Address

1-

CHECK ONE

MILEAGE

BEGIN:

ENRDUTE

F

CALL TYPE AS REC'D. 0 Emergency o Non·Emergency r::-:-::::-::-:-::==:-::-:~=::c_:_:---------------L----=D'-S::.:t::.::an.::..d ..::2by'----_l CARE IN PROGRESS ON ARRIVAL None 0 Citizen 0 PO/Fa/Other First Responder 0 Other EMS

I

Previous PCR Number

0 Extrl'catl'on requl'red

:;;;;:..;=

FROM SCENE

COMPLETE FOR TRANSFERS ONLv Transferred from [IT] D No Previous PCR 0 Unknown if Previous PCR

o

minutes

I

A~~R~M~~ ~I=::=~::::==

0 Residence 0 Health Facility 0 farm 0 Indus. Facility 0 Olher Work Lot. 0 Roadway 0 Recreational 0 Other

-=,,-,--,o=--J

Struck b vehic;;.;le:...-

I

j 10.

~.r~~I~ti~n- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

---,--:--

d -.) O MVA ( I seat b e t iuse

i

VEH.

---1 END

-+I~o~m..?':or:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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j

AGENCY CODE

Agency -+N..:.:a,--m..:.:e Dispatch

~:--

o

1----';-----'-i---'--i-'---jII

AT DESTIN

0 - LJ......L..l... IITlITTl

Seat belt used? 0 Ves 0 No 0 Unknown

IN SERVICE IN QUARTERS Seat UseBelt Re orted B

I=~=:=~=:

I=~~~~ '--:=~~~~

I r

0 Crew .

0 PolIce

o Patient o Other

I

PRESENTING PROBLEM

o

If fT/O{e than one checked. circle primaIy

o o o

o Airway Obstruction

o

Respiratory Arrest

D Respiratory Distress

D

o

Unconscious/Unresp. D Shock D Major Trauma Seizure 0 Head Injury 0 Trauma-Blunt Behavioral Disorder 0 Spinal Injury 0 Trauma-Penetrating Substance Abuse (Potential) 0 Fracture/Dislocation 0 Soft Tissue Injury Poisoning (Accidental) 0 Amputation D Bleeding/Hemorrhage

o Cardiac Arrest PAST MEDICAL HISTORY

o None o Allergy to o Hypertension o Seizures oCDPD o Other (List)

o o o o

R

PUPILS Normal

o Regular o Irregular

Stroke Diabetes Cardiac Asthma

Rate: o Regular o Irregular

Current Medications (List)

Rate:

D D D o

o Regular o Irregular

Alert Voice Pain Unresp.

L 0 0 0 0 0 0 D 0 D 0 0 D 0 D 0

o

o OB/GYN Burns Environmental D Heat D Cold o Hazardous Materials D Obvious Death

SKIN o Unremarkable o Pale o Coal o Warm o Cyanotic o Moist o Flushed oDr o Jaundiced o Unremarkable o Pale o Cool o Warm o Cyanotic D Moist o Flushed oDr o Jaundiced o Unremarkable o Cool o Pale o Warm o Cyanotic o Moist D Flushed oDr o Jaundiced

DC ou oP

OS

DC

OU OS oP

DC

OU oP OS

---------------~ o o o o o o o o o o o

o

o o

Moved to ambulance on stretcher/backboard Moved to ambulance on stair chair Walked to ambulance Airway Cleared Oral/Nasal Airway Esophageal Obturator Airway/Esophageal Gastric Tube Airway (EOA/EGTA) EndoTracheal Tube (E/T) Oxygen Administered @ L.P.M., Method _ Suction Used Artificial Ventilation Method _ C.P.A. in progress an arrival by: 0 Citizen 0 PD/FD/Other First Responder 0 Other ~ Time from Arrest~ C.P.A. Started @ Time ~ ~ Until C.P.R ~ L-L..L...J Minutes EKG Monitored (Attach Tracing) [Rhythm(s) I

o Medication Administered (Use Continuation Farm) r-r-I o IV Established Fluid Cath. Gauge L-l-J o Mast Inflated @ Time ) o Bleeding/Hemorrhage Controlled (Method Used: ) o Spinal Immobilization Neck and Back o Limb Immobilized by 0 Fixation 0 Traction o (Heat) or (Cold) Applied o Vomiting Induced @ Time _ _ Method _ _ o Restraints Applied. Type o Baby Delivered @ Time In County _ o Alive 0 Stillborn 0 Male 0 Female o Transported in Trendelenburg position o Transported in left lateral recumbent position o Transported with head elevated

Defibrillation/Cardioversion No. Times

o Other

IT]

D

0 Manual

0 Semi-automatic

YES

~

DRIVER'S NAME oCFR oEMT o AEMT #

AGENCY COPY/WHITE

NAME oCFR oEMT o AEMT #

NAME o CFR oEMT oAEMT #

RESEARCH COPY/YELLOW HOSPITAL PATIENT RECORD COpy /PINK

NON-HOSPITAL DISPOSITION CODES: NURSING HOME OTHER MEDICAL FACILITY RESIDENCE. ... TREATED BY THIS UNIT, TRANSPORTED BY ANOTHER UNIT REFUSED MEDICAL AID OR TRANSPORT CALL CANCELLED, STANDBY ONLY (NO PATIENT) NO PATIENT FOUND, OTHER.......

THE RULE OF NINES

\~ f ,

001 002 003

Estimation of Burned Body Surface (PERCENT)

G

8 [Front) , ,

i~

004 005 006 007 008 010

~ 18 [Back)A

) 91!

(',9

I

.

~,

l~

,j'

A18

18

l~

(

\

18 /

! ):

{) . .~.~.~~.~~. (j

; \ I

l14 \ 14 \

Hospital Receiving Agent

~

9\

IF~~tl.'~:

"'".

1

(

INFANT

ADULT

SIGNATURE

REFUSAL OF TREATMENT/TRANSPORTATION

Glasgow Coma Scale

NEGATIVA A RECIBIR TRATAMIENTOjSER TRASLADADO

Eye Opening

RELEASE

Th~i~

EXONERACION DE RESPONSABILIDADES Verbal Response

COMPLETE ON WHITE (AGENCY) COPY ONLY LLENE UNICAMENTE LA COPIA BLANCA (DE LA AGENCIAj I hereby refuse (treatment/transport to a hospital) and I acknowledge that such treatment/transportation was advised by the ambulance crew or physician I hereby release such persons from liability for respecting and following my express wishes.

Motor Response

Mediante la presente declaro que me niego a aceptar el tratamiento/traslado a un hospital y reconozco asimismo que el medico 0 el personal de la ambulan cia recomendaron ese tratamiento/traslado. Consiguientemente, eximo adichas personas de toda responsabilidad por haber respetado y cumplido mis deseos expresos.

To Pain None

2

Oriented

5

Confused

4

Patients Best Verbe Respopse

Inappropriate Words Incomprehensible Sounds

3

Arouse patient with vOice or painful stimulus.

None

1

Obeys Command Localizes Pam Withdraw (pain) Flexion (pain) Extension (pain)

6 5 4 3 2

None

1

Total GCS Score

Signed:

4 3

Spontaneous

Firma:

1

Patient's Best Motor Response Response to command or painful stimulus.

:3-15 ICD DIAGNOSTIC CODE

Witness: Testigo: - - - - -

•

INSURANCE 10#

CARRIER 1

WAS THIS A WORKERS' COMPENSATION INJURY:

2

DYES

D

NO

D

MEDICARE

2

D MEDICAID

3

D

BLUE CROSS

COMMERCIAL

4

D INSURANCE

INSURANCE CODE

PATIENT'S EMPLOYER:

D SELF PAY _

PHONE (

~

EMPLOYER'S ADDRESS

_

RESPONSIBLE PARTY ADDRESS

5

_ (=Zl"--P

_

PHONE ( RELATION

)__

Prehospital Care Report DATE

CONTINUATION FORM

Page__ of __

USE BALL POINT PEN ONLY

PRESS DOWN FIRMLY: PRINT NEATLY

RECEIVING HOSPITAL

TIME

RESP

o REGULAR

R

SHALLOW LABORED

RATE:

o REGULAR o SHALLOW o LABORED

NORMAL Lo 0 DECREASED 0 ABSENT 0 0 RALES 0 0 RONCHI 0 WHEEZES 0 NORMAL OR LD 0 DECREASED 0 ABSENT 0 0 RALES 0 0 RONCHI 0 0 WHEEZES 0 0

!,;J

o REGULAR

o SHALLOW o LABORED

0 0 0 0

R

NORMAL Lo DECREASED 0 ABSENT 0 RALES 0 RONCHI 0 WHEEZES 0

EKG

PULSE

REGULAR IRREGULAR

o DEFIS 0

J

RATE: REGULAR o DEFIBO oo IRREGULAR

J

RATE REGULAR o DEFIBC oo IRREGULAR

G.C.S.

B.P.

RATE:

R no

o

RATE:

NARRATIVE:

BREATH SOUNDS OR

RATE:

J

V V V

EO

v

M

Tot

EO

V

M

Tot

EO

v

M

Tol

MEDICATIONS DOSE m" " o Adenosine o Diazepam o Lidocaine OAlbuterol o Epinephrine o Morphine o Atropine o Furosemide o Nitroglyc. o Dextrose o Other

o Adenosine o Diazepam OAlbuterol o Epinephrine o Atropine o Furosemide o Dextrose o Other o Adenosine o Diazepam o Albuterol o Epinephrine o Alropine o Furosemide o Dextrose o Other

ROUTE

.

~"

o Lidocaine o Morphine! o Nitroglyc. o Lidocaine' o Morphine o Nitro9lYC'j

1

MEDICAL MEDICAL CONTROL FACILITY CONTROL RECORD

ON-LINE MED CTRL PHYSICIAN:

Controlled DRUG Substance Destroyed

DATE IOTY

I

DRUG DESTROYED WITNESS:

INDIVIDUAL ADMINISTERING MEDICATION and/or IN CHARGE - PLEASE PRINT -

PRINT NAME

I

SIGNATURE

COPYRIGHT 1995 NEW YORK STATE DEPARTMENT OF HEALTH

DOH-34" (2196)

AGENCY COPY

SIGNATURE (OPTIONAL)

MD 10#

PRINT NAME

LICENSE #

SIGNATURE

I

EMTIAEMT CERT NUMBER

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I EMS 1()()A