2.3 Completion of PCR

C/C

chief complaint, patients own words

What is to be written in “History” section?

description of scene and mechanism, appearance of patient, history and events leading up to C/C and past medical problems.

What is to be written under “Medications”?

All medication taken by the patient, over the counter or prescription, herbs, etc.

What is to be included in the “on exam” section?

include all negatives, LOC, ABCs, and deadly bleeds. Head to toe order, front to back.

what should be included in the “procedures and treatment” section?

Use correct codes and time. Assessment, vitals, medication given (dosage, site), how patient was moved and their response to treatment.

What is a supplementary care report

used for extra space on a PCR

if used don’t use the history or exam portions of original PCR and instead write see supplemental.