Corona Volunteer Ambulance PCR

1
Corona Volunteer AmbulancePCR
2
(No Transcript)
3
DATE
4
DATE
2
5
0
5
0
1
Fill in all the boxes Ex 01/20/05 or
12/25/05 Dont leave any blanks Also make sure
the date is correct
5
RUN NUMBER
LEAVE THIS BLANK FOR OFFICE USE
6
AGENCY CODE
7
AGENCY CODE
0
0
7
3
4
4
CORONA VAC AGENCY CODE WILL ALWAYS BE 007344
FILL IN ALL THE BOXES
8
VEHCILE I.D.
9
VEHCILE I.D.
-
C
4
HERE YOU ENTER THE DESIGNATED I.D. OF THE
VEHICLE Ex THE 1992 AMBULANCE VEH. I.D. IS C5 or
C 5 THE 1990 AMBULANCE VEH I.D. IS C4 OR C 4.
RIGHT JUSTIFTY
10
AGENCY NAME
AGENCY NAME
11
THE AGENCY NAME FOR CORONA VAC WILL ALWAYS BE THE
SAME. IT MAY BE WRITTEN IN SEVERAL WAYS. Ex
CORONA COMMUNITY VOLUNTEER AMBULANCE CORPSCORONA
V.A.C.CORONA AMBULANCEMAKE SURE THIS IS LEGIBLE
AGENCY NAME
12
DISPATCH INFORMATION
13
ENTER THE CALL TYPE GIVEN FROM THE DISPATCHER OR
OVER THE PHONE.Ex CARDIAC, STABBING, UNC, MVA
IF POSSBLE ENTER THE CAD FROM EMS OBTAINABLE
FROM MARS
DISPATCH INFORMATION
14
CALL LOCATION
15
ENTER THE LOCATION OF THE EMERGENCY GIVEN FROM
DISPATCH OR OVER THE PHONEEx 104-38 47TH
AVEROOSEVELT AVE / JUNCTION BLVDLIE/GCP YOU
MAY ALSO ENTER A SPECIFIC NAME.Ex SHEA
STADIUMFLUSHING MEADOW PARKREGO PARK NURSING
HOME
CALL LOCATION
16
CORONA VOLUNTEER AMBULANCE CORPS
CARDIAC CAD1234
123-01 ROOSEVELT AVE
17
ENTER THE LOCATION CODE OF THE BOROUGH THE
EMERGENCY IS IN.Ex IN OUR CASE THE LOCATION FOR
EMERGENCY IN THE CORONA WILL BE 7096 (QUEENS).IF
THE EMERGECY WAS IN BROOKLYN THEN THE LOCATION
CODE WOULD BE 7095
LOCATION CODE
18
7
0
9
6
19
ENTER THE MILEAGE ONLY WHEN YOU TRANSPORT THE
PATIENT IN YOUR AMBULANCE.NO NEED TO ENTER
ANYTHING IF YOU DONT TRANSPORT, GET CANCELLED,
NO PATIENT FOUND,ETC.
MILEAGE
20
FIRST ENTER THE BEGINNING MILEAGE, WHEN PATIENT
IS ABOARD THE AMBULANCE LEAVING FROM SCENE (10
82)THEN ENTER THE ENDING MILEAGE, WHEN PATIENT
IS REMOVED FROM THE AMBULANCE, AT DESTINATION (10
81)AND LAST ENTER THE TOTAL MILEAGE IT TOOK
TO TRANSPORT THE PATIENT.
MILEAGE
21
TIMES WILL BE WRITTEN IN MILITARY TIMEEx 735
AM 0735 115 PM 1315 1030 PM
2230 1220 AM 0020
TIMES
22
CALL RECD THE TIME DISPATCH RECEIVED THE CALL.
MAY BE THE SAME AS THE ENROUTE TIME.ENROUTE (10
63) THE MOMENT YOU START RESPONING TO THE
EMERGENCY CALL, EVENT, OR PRE-ARRANGED
ASSIGNMENT.AT SCENE (10 88 or 10 84) THE
TIME YOU ARRIVAL AT THE PICK UP SITE (CALL
LOCATION) OR SPECIAL EVENT.FROM SCENE (10 82)
ENTER THE TIME YOU ARE LEAVING WITH THE PATIENT
TO YOUR DESTINANTION.AT DESTINANTION (10 81)
ENTER THE ARRIVAL TIME AT YOUR DESTINANTION,
UNLOADING THE PATIENT.IN SERVICE (10 98) ENTER
THE TIME WHEN THE CALL OR EVENT IS FINISHED,
COMPLETED, AND READY FOR THE NEXT CALL
1 0 6 3
1 0 8 8
1 0 8 2
1 0 8 1
1 0 9 8
TIMES
23
EMERGENCY WHEN THE USES OF LIGHTS AND SIREN TO
RESPONSE TO A CALL FOR A POTIENTIAL PATIENT TO BE
TRANSPORTED TO THE E.R..NON EMERGENCY WHEN
THE CALL DOES NOT REQUIRE AN IMMEDIATED RESPONSE
TO THE E.R. Ex DOCTORS APPOINTMENT,TAKE HOME,
PREARRANGED CALLS.STAND BY WHEN WE COVER A
PREARRANGED SPECIAL EVENT Ex BASEBALL (METS),
BASEKETBALL (ST. JOHNS) ETC.
CALL RECEIVED AS
24

CALL LOCATION TYPE
INDICATE WHAT TYPE OF LOCATION IS THE EMERGENCY
IN. Ex SOMEONES HOME WOULD BE RESIDENCE A CALL
IN A DOCTORS OFFICES OR NURSING HOME WOULD BE
HEALTH. AN EMERGENCY ON THE LIE WOULD BE ROAD
25
(No Transcript)
26
(No Transcript)
27

WRITE IN PATIENTS FIRST NAME
WRITE IN PATIENTS LAST NAME
IF UNABLE TO OBTAIN (UTO) PATIENTS FULL NAME
THEN WRITE IN UTO AND WRITE UNKNOWN MALE OR
UNKNOWN FEMALE. USE ONE BOX FOR EACH LETTER.
28

PATIENTS ADDRESS
HERE YOU WOULD ENTER THE PATIENTS HOME ADDRESS,
WHERE THEY LIVE OR THEIR MAILING ADDRESS, WHAT
EVER THEY CONSIDER TO BE THEIR PLACE OF RESIDENCE.
29

PATIENTS ADDRESS
ENTER THE HOUSE NUMBER AND STREET NAME Ex 104
38 47 TH AVE 123 01
ROOSEVELT AVE 34 28 101 ST USE ONE BOX FOR
EACH LETTER OR NUMBER
30

PATIENTS ADDRESS
ENTER THE APARTMENT NUMBER IF ANY Ex 2A, D3,
BASEMENT OR PH FOR PRIVATE HOUSE
31

PATIENTS ADDRESS
ENTER THE NAME OF THE CITY WHERE THE PATIENT LIVE
IN. Ex NYC CORONA FLUSHING BROOKLYN
32

PATIENTS ADDRESS
ENTER THE STATE ABBERVIATION WHERE THE PATIENT
LIVE IN. Ex NEW YORK NY PENNSYLVANIA PA NEW
JERSEY NJ
33

PATIENTS ADDRESS
ENTER THE POSTAL ZIP CODE OF THE PATIENT
ADDRESS Ex 11368 11355 11103
34

PATIENTS ADDRESS
WHEN EVER YOU ARE UNABLE TO OBTAIN ANY PART OF
THE PATIENTS ADDRESS ENTER UTO IN THE BOXES.
35

PATIENTS AGE
ENTER THE AGE OF THE PATIENT Ex PATIENT IS 26
Y/O THEN ENTER 026 PATIENT IS 1 Y/O THEN ENTER
001 IF PATIENTS AGE IS GIVEN IN DAYS, 26 DAYS
OLD THEN ENTER 26D IF PATIENTS AGE IS GIVEN IN
MONTHS, 6 MONTHS OLD THEN ENTER 06M
36

PATIENTS AGE
IF UNABLE TO OBTAIN THE PATIENTS AGE, MAKE AN
APPROXIMATION OF THE PATIENTS AGE. Ex PATIENT
APPEARS TO BE 30 Y/O THEN ENTER 30
37

PATIENTS D.O.B.
ENTER THE PATIENTS DATE OF BIRTH. WRITE UTO IF
YOU ARE UNABLE TO OBTAIN THIS INFORMATION.
38

PATIENTS SEX
ENTER THE SEX OF THE PATIENT, F FOR FEMALE
M FOR MALE
39

PATIENTS SOCIAL SECURITY NUMBER
ENTER THE PATIENTS S.S. Ex 123-45-6789
ENTER UTO WHEN UNABLE TO OBTAIN
40
(No Transcript)
41

• IF THE PATIENT HAS A DOCTOR ENTER THE DOCTORS
  NAME HERE.
• IF PATIENT HAS NO DOCTOR LEAVE BLANK.

42

• IF ANY CARE WAS IN PROGRESS UPON ARRIVAL ENTER
  WHO WAS GIVING THE CARE.

43

• IF NO CARE IN PROGRESS CIRCLE IN NONE.

44

• IF CARE IN PROGRESS BY A BYSTANDER OR FAMILY
  MEMBER CIRCLE IN CITIZEN.
• IF POSSIBLE ENTER NAME OF PERSON.

45

• IF CARE IN PROGRESS BY PD, FDNY, OR OTHER FIRST
  RESPONDER, CIRCLE IN HERE
• IF POSSIBLE ENTER NAME OF PD CAR OR SHEILD
  NUMBER, ENGINE COMPANY, NAME OF FIRST RESPONDER.
• Ex 110B, SH1234 OF 110 Pct., ESU TRUCK 10
• E286, Condition 46 etc.

46

• CIRCLE THIS IN IF ANOTHER EMS UNIT IS ON SCENE
  PRIOR TO YOUR ARRIVAL.
• ALSO ENTER THE NAME OF THIS UNIT WHO IS ON SCENE.
• Ex FDNY 46A2, NYHQ 52G1,ST.JOHNS 46G2, NSUH
  46E2,
• AMR 123, TRANSCARE 456, NORTH SHORE AMB 789,
  NYHQ Q7.

47

• PAD STANDS FOR PUBLIC ACCESS DEFIBRILLATION
• IF USED PRIOR TO YOUR ARRIVAL CIRCLE THIS IN AND
  INDICATE BY WHO.

48

• FILL IN THE TYPE OF MECHANISM OF INJURY
• IF MVA IS CHECKED, INDICATE IF SEAT BELT USED IN
  PROCEDING BOX.
• IF FALL INDICATE OR APPROXIMATE HEIGHT IN FEET.
• IF THE TYPE OF MECHANISM OF INJURY IS NOT PRESENT
  WRITE IN TYPE AND FILL IN.

49

• IF THE TYPE OF MECHANISM OF INJURY IS NOT PRESENT
  WRITE IN TYPE AND FILL IN.

50

• IF EXTRICATION IS PERFORMED FILL IN THE CIRCLE,
  OBTAIN THE TIME AND ENTER IT IN MINUTES

51

• INDICATE IF SEAT BELT WAS USED AND INDICATE WHO
  REPORTED IT.

52

• ENTER THE CHIEF COMPLAINT OF THE PATIENT. THE
  C/C IS BASICALLY THE MAIN REASON WHY THEY CALLED
  FOR AN AMBULANCE.
• Ex As per Pt. My chest hurts
• As per Wife He passed out
• As per bystander He just started to shake
• Unresponsive, Cardiac Arrest, MVA, etc.

53

• In the SUBJECTIVE ASSESSMENT, you document what
  is told to you from either the patient, family,
  bystander, etc.
• Basically an elaboration of the chief complaint.
• Subjective is what they Say to you, this is your
  interview with the patient.

54

• You can also use this space to document
• Age, Sex, Mental Status, and position Patient was
  found.
• Ex 26 y/o ? A O fnd sitting on chair in
  tripod position.
• You can document your OPQRSTI assessment.

55

• PAST MEDICAL HISTORY
• VITAL SIGN
• CUPS STATUS

56

• Indicate the patients past medical history, if
  other write in medical history.
• If you run out of room, it may be placed in the
  comment section.

57

• Enter patients allergies.
• Fill in the circle and write in allergies.
• If you run out of room, it may be written in the
  comments section.

58

• Obtain all current medication the patient is
  presently on and list them here.
• If you run out of space, it could be written in
  the comment section.

59

• Enter patients vital signs here as indicated.
• Make sure there is at lease two (2) sets of vital
  sign for EVERY patient contact.
• If unable to obtain a complete set or a 2nd set
  then indicate why in the comment section.

60

• Enter the time vital signs were taken.
• Time must be in military time.

61

• Enter the respiratory rate and indicate the
  quality.

62

• Enter the pulse rate and indicate the quality.

63

• Enter the patients blood pressure here.
• Ex 120/80, 190/100
• If you obtain the B/P by palpation,
• Ex 120/P, 200/P

64

• Enter the patients level of consciousness using
  the AVPU scale.
• A Alert ( AOx3)
• V responsive to Voice
• P responsive to Pain
• U Unresponsive

65

• Enter the patients GCS.

66

• Indicate the patients pupils assessment.

67

• Indicate the patients skin condition.

68

• Indicate the patients CUPS Status.
• Critical
• Unstable
• Potentially unstable
• Stable

69
Indicate the presenting problem of the patient by
filling in the circle.If more then one
presenting problem is indicated, circle the
primary presenting problem.If presenting problem
is not present , then fill in other and write in
the P/P in the line provided.
70
LEFT LEG
PNEUMONIA
71
Here you document your findings obtain from the
Physical Assessment/Exam. What ever you find in
your Head to Toe survey gets documented here.
Both pertinent positive and negative finding.
Objective Physical Assessment
72
If you run out of room in the other sections like
subjective, objective, past medical history,
medication, or allergies, or if addition useful
information is given to you later on, it can be
documented here.
73
Addition information like, a back unit 46y2,
46g3,other units ACR for reference,who
transported the patient,patient last admitted,
last meal
74
In the Treatment Given, you fill in the boxes
that apply to the treatment given to the
patient.If treatment that was given is not
present, then fill in other and document the type
of treatment.
75
In the Disposition, you must write in either the
name of the hospital or the type of disposition
the call ends up to be.
76
For example If going to a hospital write in the
hospital's name.ELMHURST HOSPEGHNEW YORK
HOSPITAL QUEENSNYHQST. JOHNS HOSPITAL
77
If patient does not get transported to hospital,
then document what happen to patient
78
Ex If the patient is transported to a home write
in RESIDENCE and write in the address
79
(RESIDENCE) 104-38 47 AVE CORONA NY
(Drs Office) 104-20 CORONA NY 11368 1FL
REGO PARK NURSING HOME
80
Enter the number that coincide with the
disposition of the patient.Each hospital has
its own different DISP. CODE.Each non-hospital
disposition has a DISP. CODE located on the back
of the PCR.
81
These are your Non-Hospital Disp. Code you should
be using.
82
Here you enter ONLY the name and EMT of YOUR
crew.Dont enter the name and of other units,
document that information in your comments if
need so.
83
Obtain the signature of the nurse receiving the
patient at the hospital, nursing home, Drs
office, or other type of medical facility.If
patient is not being dropped off at a medical
facility then obtain the signature of the person
taking responsibility of patient.
84
When you have a patient who wants to RMA, have
them sign here and witness in the box.
85
It is also a good idea sometime to read it to
them or have them read it before signing
86
GCS is used to determine mental status of the
patient. Useful if the patient starts to
deteriorates or improve
87
(No Transcript)
88

• Enter the patients GCS.

89
The rule of nine is used for burn victims to
estimate the percentage of body surface burned.
90
Since we have our own billing form, we don not
use this portion of the PCR.
91

• Take your time in writing the PCR
• Be neat, clear, complete, and as accurate as
  possible.
• Keep in mind, to write if someone had to read
  your PCR, will they be able to understand it.
• Double check your paperwork with yourself and
  your partner(s).
• Before you leave the corps make sure all the
  paperwork is complete, together, and placed in
  the appropriate box.

92

• FILL IN EACH CIRCLE COMPLETELY
• ONLY USE ONE BOX FOR EVERY LETTER OR NUMBER
• MAKE SURE YOU OBTAIN A SIGNATURE FOR YOUR PCR AND
  BILLING FORM
• THE WHITE AND YELLOW COPY YOU BRING BACK AND THE
  PINK STAYS AT THE HOSPITAL
• TAKE YOUR TIME, DO IT RIGHT