PCS Cross Check — ACR (Proof of Concept)

Glasgow Coma Scale	Pediatric Coma Scale
Eye	Verbal	Motor	Eye	Verbal	Motor
4 Spontaneous	5 Orientated	6 Obeys commands	4 Spontaneous	5 Coos or babbles	6 Obeys commands
3 To voice	4 Confused	5 Localizes (pain)	3 To speech	4 Irritable, constant cry	5 Withdraws from touch
2 To pain	3 Inappropriate words	4 Withdraws (pain)	2 To pain	3 Cries to pain	4 Withdraws from pain
1 None	2 Incomprehensible	3 Flexion (pain)	1 None	2 Moans to pain	3 Flexion to pain
	1 None	2 Extension (pain)		1 None	2 Extension to pain
		1 None			1 None

Glasgow Coma Scale

Pediatric Coma Scale

Eye

Verbal

Motor

Eye

Verbal

Motor

4 Spontaneous

5 Orientated

6 Obeys commands

4 Spontaneous

5 Coos or babbles

6 Obeys commands

3 To voice

4 Confused

5 Localizes (pain)

3 To speech

4 Irritable, constant cry

5 Withdraws from touch

2 To pain

3 Inappropriate words

4 Withdraws (pain)

2 To pain

3 Cries to pain

4 Withdraws from pain

1 None

2 Incomprehensible

3 Flexion (pain)

1 None

2 Moans to pain

3 Flexion to pain

1 None

2 Extension (pain)

1 None

2 Extension to pain

1 None

APGAR Score (at 1 & 5 min — don’t wait for APGAR to begin resuscitation)
Parameter	0	1	2
Appearance	Blue or pale	Pink body, blue extremities	Completely pink
Pulse (BPM)	0 (absent)	Slow (<100)	>100
Grimace	None	Some grimace	Good grimace
Activity / tone	None, limp	Some flexion	Active motion
Respiratory effort	Absent	<60/min	Good, crying

APGAR Score (at 1 & 5 min — don’t wait for APGAR to begin resuscitation)

Parameter

Appearance

Blue or pale

Pink body, blue extremities

Completely pink

Pulse (BPM)

0 (absent)

Slow (<100)

>100

Grimace

None

Some grimace

Good grimace

Activity / tone

None, limp

Some flexion

Active motion

Respiratory effort

Absent

<60/min

Good, crying

Normal Pediatric Vital Signs
Age	Resp. rate	Heart rate
0–3 months	30–60	90–180
3–6 months	30–60	80–160
6–12 months	25–45	80–140
1–3 years	20–30	75–130
6 years	16–24	70–110
10 years	14–20	60–90

Normal Pediatric Vital Signs

Age

Resp. rate

Heart rate

0–3 months

30–60

90–180

3–6 months

30–60

80–160

6–12 months

25–45

80–140

1–3 years

20–30

75–130

6 years

16–24

70–110

10 years

14–20

60–90

Patient Demographics

Last Name

First Name

Health Card (OHIP)

Version Code

Date of Birth

Address

City

Postal Code

Phone

Alt Phone

Preferred Language

Interpreter Required?

Emergency Contact / SDM

Name

Relationship

Phone

Primary Care Provider

Physician / NP Name

Phone

Fax

Clinic Name

Program Enrollment

Enrollment Date

Assigned Paramedic(s)

Referral Source

Program

Reason for Referral

Program Goals

Status

Consent

Medical History Synced to 911 ACR

Active Conditions / Diagnoses

Current Medications

Allergies & Adverse Reactions

Paramedic Notes

Encounter History

Encounter Details

Date

Time

Duration (min)

Visit Type

Paramedic Name

Cert Level

Vital Signs

Blood Pressure (mmHg)

HR (bpm)

RR (/min)

SpO₂ (%)

Temp (°C)

BGL (mmol/L)

Pain (0–10)

Weight (kg)

GCS-E

GCS-V

GCS-M

Assessment

Chief Complaint / Reason for Visit

Subjective (S)

Objective (O)

Assessment / Clinical Impression (A)

PRISMA-7 Frailty Screen Score ≥ 3 = At Risk

1.Are you more than 85 years old?

2.Male sex?

3.Do you have health problems that require you to limit your activities?

4.Do you need someone to help you on a regular basis?

5.Do you have health problems that require you to stay at home?

6.In case of need, can you count on someone close to you? (No = 1 pt)

7.Do you regularly use a stick, walker, or wheelchair?

PRISMA-7 Notes

Falls Risk Assessment

Falls in Past 12 Months

Falls Risk Level

Timed Up & Go (seconds) — ≥ 12 sec = fall risk

Falls Notes

Medication Reconciliation

Medications reviewed and reconciled with patient record this visit

Medication Notes / Changes

Interventions & Education

Interventions Performed

Patient Education Provided

Referrals Made

Disposition & Plan

Disposition

Next Visit Date

Next Visit Notes

Care Plan Changes

Attestation

I attest that the information documented in this encounter record is accurate and complete to the best of my knowledge, and that care was provided within my authorized scope of practice.

Paramedic Name (Print)

Cert # / Badge #

Signed At

Discharge Patient

Delete Patient Record?

Medic Sign-In

Shift Setup