Patient Care Report Form PDF Details

The Patient Care Report form is a comprehensive document utilized by the Carbon Hill Volunteer Rescue Squad to meticulously record every aspect of patient care provided during emergency medical services. This form captures a variety of crucial information, including the service name, vehicle number, incident number, and date, along with the patient’s demographic details such as name, age, gender, and place of residence. It further delves into the patient's chief complaint, medical history—including any known allergies and medications—as well as vitals like the level of consciousness, speech, skin color, respiration, pulse, and pupil reaction. The form catalogues the medical conditions treated, from abdominal pain and cardiac arrests to various forms of trauma, highlighting the urgency of each situation. Additionally, it details the treatment administered on scene, encompassing both the use of specific medications and other interventions. A unique section is dedicated to patients who decide against receiving further treatment or transport, requiring their acknowledgment of the risks involved in refusing professional medical assistance. This acknowledgment is reinforced by the signatures of both the patient and a witness. Completing the form, the attending crew members document their names and EMS license numbers, ensuring accountability and a seamless transfer of care when required. Thus, the Patient Care Report form serves not only as a record of the patient's condition and the care provided but also as a critical communication tool among healthcare providers.

QuestionAnswer
Form NamePatient Care Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespatient care report template, ems report template, ems pcr template, patient care report template word

Form Preview Example

 

 

 

Carbon Hill Volunteer Rescue Squad

 

Patient Care Narrative / BLS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE NAME / VEHICLE#

 

 

 

SERVICE #

 

INCIDENT #

 

 

 

 

 

 

 

 

 

TODAY’S DATE

CARBON HILL VOL RESCUE SQUAD

 

 

 

149

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCIDENT LOCATION

 

 

 

 

 

 

 

 

 

 

 

 

TRANSPORTED TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT

LAST NAME

 

 

FIRST

 

 

 

M.I.

 

 

AGE

 

Gender

 

 

 

 

DATE OF BIRTH

______________________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

PATIENT ADDRESS

 

 

 

 

 

CITY

 

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHIEF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLAINT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medications

 

Pt. States None

Unknown

 

Brought W/Pt.

List:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES

 

Pt. States None

Unknown

 

List:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL

 

Pt. States None

Unknown

 

Asthma

 

 

Cardiac

COPD

 

 

Renal Failure

Seizure

 

 

 

HISTORY

 

Stroke/CVA

Cancer

 

CHF

 

 

Diabetes

Htn

 

 

Other________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signs

 

L.O.C.

SPEECH

SKIN

COLOR

RESPIRATION

PULSE

 

 

PUPILS

 

 

 

 

Call Received

 

___Alert

____Coherent

____Normal

____Normal

 

____Normal

____Normal

____Reactive L / R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___Voice

____Incoherent

____Moist

____Cyanotic

 

____Rales

____Rapid

____Dialated L/ R

 

 

 

 

 

 

Patient

 

___Pain

____Slurred

____Hot

 

____Pale

 

____Distressed

____Slow

 

 

____Equal

 

 

Dispatch

 

On Scene

 

 

 

 

 

 

 

 

 

 

Dispatch

 

 

___Unrespon

____Silent

____Cool

____Flushed

 

____Absent

____Absent

____Unequal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________ __________

__________

__________

__________

__________

_________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___Abdominal Pain

____Pediactric Cardiac Arrest

____Coma

 

 

_____Near Drowning

_____Stroke

 

 

Times

 

 

 

Medical Condition

 

___A.M.S.

 

____Cardiac Chest Pains

 

____Fx / Disloc.

____Poisons / OD

_____Suspect Spinal Inj

 

 

 

 

 

 

___Burns

 

____Childbirth

 

____Hypoglycemia

____Seizures

 

____Death in the Field

 

 

 

 

 

 

 

___Amputation

 

____Cardiac Dysrhythmias

 

____Head Trauma

____Eclampsia / Pre

____Syncope

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___Anaphylaxis

____Ped. Dysrhythmias

 

____Hyperthermia

____Resp Distress

_____Vaginal Bleeding

 

 

 

 

In Service

 

 

___Cardiac Arrest

____Congestive Heart Failure

____Hypothermia

____Shock

 

______ General Patient Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIME

B / P

P

Resp.

TREATMENT

Patient Assisted

Medications

Nitroglycerin ____

Auto inhaler _____

Auto Injection Epinephrine ____

MEDICATIONS GIVEN

QTY.

DOSE

_______

______Glucose Paste

_______

______ Charcoal

NARRATIVE

REFUSAL OF TREATMENT / TRANSPORT

This is to certify that I am refusing Treatment / Transport and have been informed of the risks of doing so.

X_______________________________________

___________

X__________________________________________

_____________

Patient Signature

Date/Time

Witness Signature

Date/Time

 

 

 

 

______________________________________________________

________________

_________________________________________________________

___________________

Crew Member # 1

EMS License #

Crew Member # 3

EMS License #

_______________________________________________________

________________

_________________________________________________________

____________________

Crew Member # 2

EMS License #

Crew Member # 4

EMS License #

How to Edit Patient Care Report Form Online for Free

Very few things are easier than preparing documentation through our PDF editor. There isn't much you need to do to update the ems pcr template document - just simply adopt these measures in the next order:

Step 1: At first, click on the orange "Get form now" button.

Step 2: So you will be on the file edit page. You can add, enhance, highlight, check, cross, insert or delete areas or words.

The PDF form you plan to fill in will contain the next sections:

part 1 to completing patient report template

You need to fill in the l a c i d e M, n o i t i, d n o C, Amputation Cardiac Dysrhythmias, D i s p a t c h T m e s, Anaphylaxis Ped Dysrhythmias, In Service, Burns Childbirth Hypoglycemia, Cardiac Arrest Congestive Heart, TIME, B P, Resp, TREATMENT, Patient Assisted Medications, and Nitroglycerin box with the required particulars.

Filling in patient report template stage 2

The program will request for additional information in order to automatically fill out the field REFUSAL OF TREATMENT TRANSPORT, X X Patient Signature DateTime, Crew Member EMS License, and Crew Member EMS License.

Entering details in patient report template stage 3

Step 3: Choose the "Done" button. Now you can upload the PDF file to your gadget. Besides, it is possible to send it through electronic mail.

Step 4: Make no less than a couple of copies of the form to keep clear of any sort of potential difficulties.

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