Republic of the Philippines

Department of Health
CARAGA REGIONAL HOSPITAL DRR – 04
Rev. No. 0
Surigao City Effectivity: 02/01/18

Ambulance Patient Care Report (PCR)

Date: Incident No: Nature of Call: Location:
Dispatched: En Route: At Scene: Transport: At Hospital: In Service:

Patient Information
Name: Allergies:
Age: Medications:
Sex: Past Medical History:
Civil Status: Chief Complaint:
Address:
Weight (in kg):
Vital Signs
Time: BP: Pulse: Respiration: Sao:
Time: BP: Pulse: Respiration: Sao:
Time: BP: Pulse: Respiration: Sao:

EMS Treatment
(Circle all that apply)
Oxygen @ ____L/min via (circle one): Assisted Ventilation Airway Adjunct CPR
NC NRM BVM Device
Defibrillation Bleeding Control Bandaging Splinting Other:

Narrative

(For continuation, please use the back)

Medical Director(s) on Line: /

Ambulance Nurse on Duty: ______________________ WAIVER AND RELEASE OF LIABILITY

Driver: ___________________________ I, the undersigned, give my consent for the person identified above
to be transported by Caraga Regional Hospitaland will assume all
CERTIFICATE OF APPEARANCE liability for my/their participation in this activity/event and any
injury that may result during the transport or at the event/activity.

This is to certify that. __________________________ Further, by signing below:

and _______________________ personally appeared
on this office on ____________________________ to
__________________________________________ .
This certification is issued upon on whatever legal
purpose in may serve. Issued this day of __________
at ________________________________________ .
1.)I will not hold Caraga Regional Hospital, its officers, agents,
employees, assigns or anyone acting on its behalf, responsible or
liable for injury occurring to the named person in the course of such
activities or such travel.
2.)I hereby accept financial responsibility for personal items lost by
the person identified herein.
3.) I authorized Caraga Regional Hospital to transport and to obtain,
through a physician/hospital of its own choice, any emergency
medical care that may become reasonably necessary for the person
in the course of such activities/ events or such travel, and agree to
accept the cost of the transportation and/or treatment by medical
personnel or facility.
4.) I accept full responsibility and hereby grant permission for me or
my minor child to travel with Caraga Regional Hospital.

ER Personnel / Receiving Officer

Signature over Printed Name Relationship
 Vital Signs
Time: BP: Pulse: Respiration: Sao:
Time: BP: Pulse: Respiration: Sao:
Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Time: BP: Pulse: Respiration: Sao:

Narrative