Hatzoloh Patient Care Report (PCR)

  • Hatzoloh Patient Care Report (PCR)

    Complete all fields accurately for every patient encounter. This form is for internal use by authorized EMS personnel only.
    • Patient Information  
    • Date of Birth*
       - -
    • Incident Information 
    • Date of Incident*
       - -
    • Was 10-09 Activated?*
    • Initial Approach 
    • Level of Responsiveness (AVPU)*
    • Oriented*
    • Airway*
    • Respiration*
    • Pulse*
    • Pulse Location
    • Nature of Call 
    • Nature of Call*
    • Medical History 
    • Past Medical History
    • Infectious Diseases?*
    • Allergies?*
    • Objective Assessment of Trauma (If Applicable) 
    • Mechanism of Injury/Trauma
    • Type*
    • Passenger Restrained*
    • Airbag Deployed*
    • Entrapped in Vehicle*
    • Interventions 
    • Interventions Performed*
    • Access Refused 
    • Access Refused By*
    • Clinical Support 
    • Clinical Support
    • Child Birth 
    • Bleeding Control 
    • Bleeding Control*
    • Pressure*
    • Immobilizations 
    • Immobilizations*
    • Collar Type*
    • Medications 
    • Cardiac Arrest (CPR) 
    • Presumed Cause*
    • Initial Observed Rhythm (if applicable)
    • Termination / Non-Initiation of Resuscitation Efforts
    • Airway 
    • Airway*
    • Canula Type*
    • Vitals 
    •
    • Pain
    • Narrative / Additional Information 
    • Disposition 
    • RMA 
    • RMA Type*
    • The following apply to myself or the patient on whose behalf I legally sign this document (check all that apply)*

    • I understand that the Hatzoloh personnel are not physicians and are not qualified or authorized to make a diagnosis and that their care is not a substitute for that of a physician. I recognize that I may have a serious injury or illness which could get worse without medical attention, even though I (or the patient on whose behalf I legally sign this document ) may feel fine at the present time.


      I understand that I may change my mind and call 9-1-1 if treatment or assistance is needed later. I also understand that treatment is available at an emergency department 24 hours a day.


      I acknowledge that this advice has been explained to me by Hatzoloh personnel and that I have read this form completely and understand its provisions. I agree, on my own behalf (and /or on the behalf of the patient for whom I legally sign this document), to release, indemnify and hold harmless all Hatzoloh providers and their officers, members, employees, directors, supervisors or other agents, and the Hatzoloh orgainzation itself, from any and all claims, actions, causes of action, damages, or legal liabilities of any kind arising out of my decision, or from any act or omission of the EMS providers, the organization itself or their personnel

    • PATIENT / GUARDIAN REFUSES TO SIGN: I attest that the patient / guardian has refused care and/or transportation by the emergency medical services providers. The patient / guardian was informed of the risks of this refusal and refused to sign this form when asked by the EMS providers.

    • Signatures 
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