PCR Instructions, Section 3

Reminder: completely fill in all appropriate circles.

Past Medical History	Completely fill in all appropriate circles. List allergies and current medications in the spaces provided. If necessary, continue the "past medical history" in the Comment section.
Vital Signs	Enter each set of vital signs in the space provided. If more than three sets are taken, record them in the Comment section or on a Continuation Form. (Note: The statistical program uses only complete sets of vital signs-- respiration, pulse, blood pressure-- that are recorded in numbers; vital signs recorded by terms such as "normal" or "stable" are not included.)
Time	Enter the time each set of vitals are taken. Only enter military time in this section. To calculated military time, see General Instructions.
Resp.	Record the number of respirations per minute. Also fill in the circle that best describes the quality of respiration (regular, shallow, labored).
Pulse	Record the pulse rate per minute. Also fill in the circle that best describes the patient's pulse (regular, irregular).
B.P.	Record the blood pressure (B.P.) as systolic over diastolic pressure. If you are unable to take the patient's blood pressure, explain the reason in the Comment section. If the blood pressure is taken by palpation, record the systolic pressure over P. Example: 90/P.
Level of Consciousness	This section denotes level of consciousness, using the acronym AVPU, which stands for: A - Alert--Knows his name (person): knows where he is (place); knows day of week (day). V - Verbally responds--but not able to respond correctly to all three questions above. P - Responds to painful stimulus but not oriented to person, place and/or time. U - Unresponsive to both painful and verbal stimulus. Fill in the circle that most accurately describes the patient's level of consciousness at the time this assessment was performed.
Glasgow Coma Scale (CGS)	The Glasgow Coma Scale (GCS), based upon eye opening, verbal, and motor responses is a practical means of monitoring changes in level of consciousness. If response on the scale is given a number, the responsiveness of the patient can be expressed by summation of the figures. Lowest score is 3; highest is 15. (Refer to GCS guide on back of PCR). Record the numeric total of the highest level of responses to the level of consciousness survey. Example:    GCS     Eye Opening - To Pain     2     Verbal Response - Confused     4     Motor Response - Withdraw (Pain)    4     TOTAL GCS SCORE     10
Pupils	Fill in the circle that best describes each eye's response to light. Record the right pupil under the R column and the left under the L column. These columns are the patient's right and left sides. Indicate in the Comment section if the pupils are normally uneven or if a patient has an artificial eye.
Skin	Fill in only the circles that apply. Mark "unremarkable" only if all three assessment categories (temperature, moisture and color) are within normal limits.
Status	Fill in the circle that most accurately describes the patient's status: C - CPR/arrested patient: cardiac arrest, respiratory arrest, patient being ventilated U - Unstable patient: severe upper airway difficulties, serious chest trauma, decompensated shock, rising intracranial pressure, uncontrollable external hemorrhage, penetrating injury to head, neck, chest, abdomen, pelvis P - Potentially unstable patient: early signs of compensated shock, kinematics or injuries suggest "hidden injury", major isolated injury S - Stable patient: minor isolated injuries, uncomplicated extremity injuries.
Objective Physical Assessment	Enter in this section a summary of the primary and secondary assessment of the patient.
Comments	Enter in this section information obtained during Primary and Secondary Survey that should be reported, or information that is not described in enough detail in any other part of this form. If there is not sufficient room, use additional PCRs or a Continuation Form if available. Attach additional sheets used to the agency (white), and hospital (pink) copies of the PCR.