BMRC PCR Guide

When To Fill Out

For any patient for whom you perform a medical assessment or intervention beyond simple First Aid (i.e. anything beyond handing out a band-aid or ice pack).

When Not To?

Simple First Aid or comfort items requested by patients (i.e. band-aids, ice packs) who refuse and/or do not require assessment.

Key Takeaways / Common Mistakes

  • Demographics information is required for every patient. Try your best to acquire it.
    Pro Tip: Ask for their ID!
  • Chief complaint should be in quotes (e.g., “I drank too much,” not EtOH). If unresponsive or incomprehensible, document as:
    > “None (Unresponsive/Incomprehensible)”
  • If A+O status is less than 4, document exactly what the patient could not report or what led you to conclude the patient was altered.
    E.g.: “Unaware of current location/city”
  • In systems assessment, document both signs and symptoms and pertinent negatives.
    E.g.: Cardiovascular: “Pedal edema.” Neurological: “CSMs in all extremities intact.”
  • Know the difference between WNL and NA:
    • Use WNL (Within Normal Limits) if the system is relevant and you have assessed it to be normal.
    • Use NA (Not Applicable/Assessed) if the system is irrelevant to the call.
  • For allergies, medications, and past medical history:
    If none reported, do not leave blank. Write:
    > “None reported/Pt denies”

Narrative Structure

All PCRs should follow this general format:

MRC [1] [dispatched/flagged down] to/for [“X YOM/F”] @ [Location] AOS (Arrived on Scene) to find [X YOM/F]… initial impressions (positioning, A+O status, ABCs, skin signs, etc.)… with Chief Complaint: [“____”]
Upon assessment, document all relevant signs, symptoms, assessment responses, and pertinent negatives. Skip items that are already clearly documented elsewhere.
If applicable: ALS requested via [UCPD emergency line/911/radio] @ [time]. Mention immediately if done on arrival.
Transferred care to [BER (Berkeley Fire) Engine/Medic #] or “Pt released after treatment and refused additional service.”
If releasing pt: include rationale for safe release without ALS.
If moving pt: “Pt securely loaded onto [gurney/stair chair] and moved to [destination] without incident.”

Signatures

  • Patient Signature: MUST be obtained, or document why not obtained.
    If minor/ALOC/AMS: “Pt unable to sign (reason).” A guardian or chaperone may sign if legally permitted.
  • Provider Signature: All providers involved in care must sign and approve the PCR.

Acronyms

Please use only approved abbreviations and acronyms.
See the full list here: ACPHD Approved Acronyms List (PDF)

Sample PCR Examples

Use the following examples as reference for appropriate narrative structure and documentation style: