Practice PCR Form

Practice PCR Form
Employee Information
Employee Name*

First NameLast Name
Employee Email Address*
example@example.com
Unit:*
Date*

MonthDayYear
Date
Division*
Practice PCR

Call Information
Call Location

Street Address

Street Address Line 2

CityState

Zip Code
Dispatched Date/Time

MonthDayYear
DateHourMinutes

Insurance
Add Payor
Select an Insurance Provider*

Aetna *Primary Carrier*BCBS PO Box 1407Cigna Health Plan PO Box 182223GHI *Primary Carrier*HIP *Primary Carrier*Local 1199 PO Box 1007Magnacare 825 East Gate BlvdMedicaid WestchesterMedicareOxford *Primary Carrier*POMCOSelf PayTri-Care North Region PO Box 7889United *Primary Carrier*

Vital Signs 1
PTA*

YesNo
Who Performed*
Patient Position*
BP Method
Blood Pressure

Systolic Diastolic

Pulse

	Pulse	Regularity	Strength	Method

Respiratory*

	Rate	Regularity	Effort

Pulse Oximetry

	Pulse Oximetry	Source

EtCO2

	EtCO2	EtCO2

Capillary Refill
Glucose

GCS*

	Eyes	Verbal	Motor	GCS Qualifier

ECG
Method of Interpretation
EKG Type
Lung Sounds - Left
Lung Sounds - Right
Stroke Scale
Stroke Scale Type
Thrombolytic Screen
Carbon Monoxide
LOC*

Pupil Dilation

	Left	Right

Pupil Reaction

	Left	Right

Pain

	Scale	Scale Type

Skin

	Color	Temperature	Moisture

Vital Signs 2
Date*

MonthDayYear
DateHourMinutes
PTA*

YesNo
Who Performed*
Patient Position*
BP Method
Blood Pressure

Systolic Diastolic

Pulse

	Pulse	Regularity	Strength	Method

Respiratory*

	Rate	Regularity	Effort

Pulse Oximetry

	Pulse Oximetry	Source

EtCO2

	EtCO2	EtCO2

Capillary Refill
Glucose

GCS*

	Eyes	Verbal	Motor	GCS Qualifier

ECG
Method of Interpretation
EKG Type
Lung Sounds - Left
Lung Sounds - Right
Stroke Scale
Stroke Scale Type
Thrombolytic Screen
Carbon Monoxide
LOC*

Pupil Dilation

	Left	Right

Pupil Reaction

	Left	Right

Pain

	Scale	Scale Type

Skin

	Color	Temperature	Moisture

Outcome
Disposition*
Level of Care*
Cancellation Reason
Pt Txped to Ambulance
Final Patient Acuity
Destination

HospitalNursing Home / SNFDoctor's OfficeResidence
MRN

Narrative
Narrative*
Should be Empty: