Tips to Write Better NY State PCR’s 

PCR Legible: The PCR is written so that anyone is able to read & understand 
what is documented. There should be no “blackouts”. Mistakes should have 
one line through them & initialed. Remaining white space is not “x”ed or 
lined out. Just initial the end of your narrative. 

Patient personal information: The patients complete name, address, phone #, 
date of birth, age, sex and physician is indicated. Use None, Unknown, 
Denies or UTO(unable to obtain) instead of leaving a box blank and explain 
in comments. Care in progress section completed for every patient. 

Dispatch info/location: The Agency name, dispatch information, call 
location, check one box, call type as received, and mileage are all 
completed. Remember dispatch info is generally the type of call. 

All times recorded: Self-explanatory. Use military time and included all 
four digits for each time. The only times allowed to be missing from the 
hospital copy of the PCR are “in service” and “in quarters”. 

Chief complaint: Why the patient called the ambulance. It should be 
recorded in the patient’s own words using “quotation marks”. Duration of 
complaint should also be recorded when applicable to complaint, e.g. chest 
pain, difficulty breathing, abdominal pain, etc. If patient cannot respond, 
write “unresponsive “ as chief complaint. On trauma patients, mechanism of 
injury & seat belt use sections completed. 

Subjective assessment: Expansion of patient’s complaints describing the 
symptoms the patient has. If you document in a narrative form, you may 
start your narrative here and continue it in the objective physical 
assessments and comments sections. 

Presenting problem: At least one box checked. If more than one problem is 
checked the primary one should be circled. “Pain” & “Other” require 
further details (such as type, location, duration, & severity for pain and 
“none” for other). 

Vital Signs: At least two complete sets with times sets should be recorded. 
A baseline set when the first patient contact is made. Subsequent sets 
based on patient’s condition (every 5 minutes for unstable patients, every 
15 minutes for stable ones). If any particular vitals signs cannot be 
recorded, document reason in comments. E.g. Patient refused. Have patient 
sign RMA, circling treatment. 

Objective physical exam: Every patient should receive a detailed physical 
exam or a vectored exam based on their complaints. E.g.: 
CNS trauma - presence of distal pulse, motor, sensation findings; 
Breathing problems - lung sounds, JVD; 
Chest pain - presence of pedal edema, ascites, JVD; 
Abdominal pain - rigid or soft abdomen; 
Extremity fractures - swelling, deformity, presence of distal pulse, motor, 
sensation findings, etc. 

Past medical History/allergies: Check off all that apply. Use None, Unknown, 
Denies or UTO(unable to obtain) instead of leaving the box blank and explain 
in comments. 

Medications: List all meds including dosage when possible. Continue in 
comments if more space is needed. Use None, Unknown, Denies or UTO(unable to 
obtain) instead of leaving the box blank and explain in comments. 

Disposition/Disp.Code: This should explain how call was completed. 
Transports to hospital should have hospital name and hospital code 
documented. Proper code for calls where patient is not transported. See 
Other notes below. 

Crew names/EMT numbers: Self-explanatory. Use first name or initial when 
agency has more than one member with the same last name. 

Appropriate treatment: Remember the old saying: “If you didn’t write it 
down, it didn’t occur”. All BLS treatments should be recorded even if 
performed by ALS. No ALS treatments should be recorded on BLS PCR. Please 
remember to check off how the patient was moved to ambulance and the 
position they were transported. 

On scene time appropriate: All trauma patients classified as unstable or 
critical should be removed from the scene within 10 minutes of arrival. All 
medical patients should be removed from the scene within 20 minutes of 
arrival. If on scene times exceed this, an explanation of why should be 
documented. 

Other notes: 

All RMA’s must be documented as completely as any other patient. This 
includes vital signs, mechanism of injury and steps taken to convince 
patient to receive treatment &/or transport. 
Patients that do not complain of injuries, and do not have any mechanism of 
injury are not patients. Since they are not patients, they do not require a 
RMA. The call disposition should be recorded as “no patient found” or 
“canceled”. 
DOA’s require only one set of vital signs and should not have a blood 
pressure recorded. We must document signs of obvious death (and check that 
box as presenting problem), dependant lividity, rigor mortis, or tissue 
decomposition. If we don’t we should have treated the patient! DNR’s must 
also be documented & a copy attached to PCR. 
If a call is cancelled by ALS, it should be recorded as canceled and no 
patient information need be recorded. To do so makes it appear we had 
patient contact. E.g. ALS taking an RMA prior to BLS arriving on scene & 
beginning care. 
If you are going to omit a section because it was performed by the paramedic 
or the paramedic acted as EMT on the call, make sure to obtain a copy of the 
PCR and attach it to the BLS PCR. Document ALS PCR# and paramedic’s name in 
comments section.