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.

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.

Enter the number assigned by your dispatcher or agency.

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.

Enter the identification number of the vehicle that responds to the call. This is the number assigned by your agency.

Enter the official name of your agency or service.

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

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

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

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.

Enter the patient's address. Be as complete as possible. If the address is unknown, write "unknown."

Enter the patient's telephone number.

Enter the patient's city, state and Zip Code; include the Zip+4 if known.

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.

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.

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.

Only enter military times in this section. To calculate military time, see General Instructions.

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.

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.

Enter the time of departure from the scene.

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.

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.

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.

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.

Enter the name of the patient's personal physician.

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.

Fill in the appropriate circle, mark all that apply.

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).

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.

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).

Fill in this circle if the patient was assaulted (harmed by another person) but no weapon such as gun,knife, etc., was used.

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.

Fill in this circle if the patient was harmed by a knife or knife-like object (i.e., scissors, screwdriver).

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.

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..

Completely fill in all appropriate circles. List allergies and current medications in the spaces provided. If necessary, continue the "past medical history" in the Comment section.

Enter each set of vital signs in the space provided. If more than three sets are taken, record them in the Comment section or on a Continuation Form.
(Note: The statistical program uses only complete sets of vital signs-- respiration, pulse, blood pressure-- that are recorded in numbers; vital signs recorded by terms such as "normal" or "stable" are not included.)

Enter the time each set of vitals are taken. Only enter military time in this section. To calculated military time, see General Instructions.

Record the number of respirations per minute. Also fill in the circle that best describes the quality of respiration (regular, shallow, labored).

Record the pulse rate per minute. Also fill in the circle that best describes the patient's pulse (regular, irregular).

Record the blood pressure (B.P.) as systolic over diastolic pressure. If you are unable to take the patient's blood pressure, explain the reason in the Comment section. If the blood pressure is taken by palpation, record the systolic pressure over P.
Example: 90/P.

This section denotes level of consciousness, using the acronym AVPU, which stands for:
A - Alert--Knows his name (person): knows where he is (place); knows day of week (day).
V - Verbally responds--but not able to respond correctly to all three questions above.
P - Responds to painful stimulus but not oriented to person, place and/or time.
U - Unresponsive to both painful and verbal stimulus.

Fill in the circle that most accurately describes the patient's level of consciousness at the time this assessment was performed.

The Glasgow Coma Scale (GCS), based upon eye opening, verbal, and motor responses is a practical means of monitoring changes in level of consciousness. If response on the scale is given a number, the responsiveness of the patient can be expressed by summation of the figures. Lowest score is 3; highest is 15. (Refer to GCS guide on back of PCR).
Record the numeric total of the highest level of responses to the level of consciousness survey.
Example:    GCS
    Eye Opening - To Pain     2
    Verbal Response - Confused     4
    Motor Response - Withdraw (Pain)    4
    TOTAL GCS SCORE     10

Fill in the circle that best describes each eye's response to light. Record the right pupil under the R column and the left under the L column. These columns are the patient's right and left sides. Indicate in the Comment section if the pupils are normally uneven or if a patient has an artificial eye.

Fill in only the circles that apply. Mark "unremarkable" only if all three assessment categories (temperature, moisture and color) are within normal limits.

Fill in the circle that most accurately describes the patient's status:
C - CPR/arrested patient: cardiac arrest, respiratory arrest, patient being ventilated
U - Unstable patient: severe upper airway difficulties, serious chest trauma, decompensated shock, rising intracranial pressure, uncontrollable external hemorrhage, penetrating injury to head, neck, chest, abdomen, pelvis
P - Potentially unstable patient: early signs of compensated shock, kinematics or injuries suggest "hidden injury", major isolated injury
S - Stable patient: minor isolated injuries, uncomplicated extremity injuries.

Enter in this section a summary of the primary and secondary assessment of the patient.

Enter in this section information obtained during Primary and Secondary Survey that should be reported, or information that is not described in enough detail in any other part of this form. If there is not sufficient room, use additional PCRs or a Continuation Form if available. Attach additional sheets used to the agency (white), and hospital (pink) copies of the PCR.

Fill in the circle if the patient was moved to the ambulance on a stretcher and/or a backboard.

Fill in the circle if the patient was moved to the ambulance on a stair chair.

Fill in the circle if the patient walked to the ambulance.

Fill in the circle if the patient's airway was cleared.

Fill in the circle if an oropharyngeal or nasal airway was used.

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.

Fill in the circle if the placement of an endotracheal tube was successful. If the attempt was unsuccessful, explain in the Comment section.

Fill in the circle if the patient was artificially ventilated and record method.
Examples: mask to mouth, positive pressure.

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.

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.

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.

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).

Fill in this circle if the patient was given CPR by anyone (bystander, CFRs, your agency, etc.)

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.

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.

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.

Fill in the circle if your crew administered any medication (s). List all medications including time, dosage, and route on a Continuation Form.

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.

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.)

Fill in the circle and enter the method used to control bleeding/hemorrhage.

Fill in the circle if spinal column was immobilized. Circle "neck" or "back" or both to indicate the area(s) 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).

Fill in the circle if either heat or cold applications were used. Circle either "heat" or "cold" to note the appropriate application.

Fill in the circle if vomiting was induced. Note the time and method used. Use military time; to calculate military time, see General Instructions.

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.

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.

Fill in the circle if the patient was transported in the Trendelenburg position.

Fill in the circle if the patient was transported in the left lateral recumbent position.

Fill in the circle if the patient was transported with their head elevated.

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.

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.