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Ministry of Health
and Long-Term Care
Ambulance Call Report
Confidential when completed
1881-45 (2017/01) 7530-4714
Demographics
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Hospital Registration Number
Service Name
Service No.
CACC/ACS Call Number
Call Date
/
/
Last Name
First Name
Age
Sex
Weight (kg)
Date of Birth
/
/
Health Insurance Number
Version
Mailing Address – Street No.
Street Name
City/Town
Province
Postal Code
Country
Pick-up Location or Sending Facility (City/Town)
Same as Mailing Address Above
Pick-up Code
Clinical Information
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Date of Occurrence
/
/
Time of Occurrence
:
Chief Complaint
MOHLTC DNR Confirmation Number
Trauma Problem Site/Type
Enter the Site/Type codes.
Location (1)
Type
Mechanism
Location (2)
Type
Mechanism
Location (3)
Type
Mechanism
Incident History
Medications
Nitrates
ASA
Salbutamol
Furosemide
Insulin/Oral Diabetic Meds
Phosphodiesterase Inhibitors
Other
None
CNO
Medications – Details
Relevant Past History
Previously Healthy
Cardiac
Respiratory
Seizure
Diabetes
Psychiatric
Anaphylaxis
Cancer
Stroke/TIA
Hypertension
Other (list below)
CNO
Details
Allergies
NKA
CNO
Other – list below
Details
Treatment Prior to Arrival
None
Midwife
EFRT
Other Paramedic
Nurse
Physician
Bystander
Self
Fire
Police
Other (list below)
CNO
Details
Cardiac Arrest Information
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Arrest Witnessed By
Unwitnessed
Bystander
Trained Responder
Paramedic
Date
/
/
Start Time
:
CPR Started By
None
Bystander
Trained Responder
Paramedic
Date
/
/
Start Time
:
First Shock By
None
Bystander
Trained Responder
Paramedic
Date
/
/
Start Time
:
Physical Exam
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General Appearance
Blood thinner/Anticoagulants
Skin Colour
Flushed
Pale
Cyanosis
Jaundice
Unremarkable
Skin Condition
Dry
Clammy
Diaphoretic
Unremarkable
Head/Neck
Trachea Shifted
Midline
R
L
|
JVD
Elevated
Not Elevated
Chest
Air Entry
Bilaterally
Decreased
R
L
|
Breath Sounds
Clear
Wheezes
Crackles
Rub
Absent
Abdomen
Soft
Rigid
Distended
Tender
Mass
Pulsatile
|
RU
LU
LL
RL
Center
Back/Pelvis
Unremarkable
Extremities
Unremarkable
|
Peripheral Edema
Absent
Present
|
Pedal Pulse
Absent
Present
Screening
Positive for FREI
|
Provided by:
Patient
Other:
Ministry of Health
and Long-Term Care
Ambulance Call Report
Confidential when completed
1881-45 (2017/01) 7530-4714
Billing Copy
Demographics
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Hospital Registration Number
Service Name
Service No.
CACC/ACS Call Number
Call Date
/
/
Last Name
First Name
Age
Sex
Weight (kg)
Date of Birth
/
/
Health Insurance Number
Version
Mailing Address – Street No.
Street Name
City/Town
Province
Postal Code
Country
Pick-up Location or Sending Facility (City/Town)
Same as Mailing Address Above
Pick-up Code
Billing Information
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In my professional medical opinion ambulance use was:
Essential: a medical/other necessity
Non essential: not a medical necessity/other transport suitable
Disposition in Hospital – Emergency Dept.
Treated (observed) and released
Refused treatment and released
Transferred to another hospital
Admitted
Out Patient / In-patient / Other
O.P. Clinic
X-Ray
Ca. Clinic
Out Patient – Other
In-patient returning
In-patient discharged
Morgue
Other
Chargeable
Patient
Employer
W.S.I.B.
D.V.A.
D.N.D.
Coroner
Other
Welfare Charge
Inter-Hospital Transfer
Home Care
Homes for Special Care
Nursing Home Patient
Home for the Aged
Recipient General Welfare Assistance
Other
No Charge / Billing Evaluation
No Charge
Basic Fee
Billed by
Hospital/Clinic
Operator
Other
DND/RCMP
Social Insurance No.
Registration No.
Hospital Code
Initials
Patient’s portion
Charge for km over 40
Amount billed
Other charge
Signature (medical practitioner/approved authority)
Payment Received
1881-45 (2017/01)
7530-4714
Clinical Treatment/Procedures
Call Number
Page
of
Clinical Treatment/Procedures - Results
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#
Time
HH : MM
Procedure
Code
Crew
Mbr. No.
Reading/
EtCO2
Code
Resp.
Rate
Pulse
Rate
B/P
Sys/Dia
Temp.
SpO2
Pupils
R ±
Pupils
L ±
Dose/Unit
Route
GCS
Pain
Scale
1
:
2
:
3
:
4
:
5
:
6
:
7
:
8
:
9
:
10
:
11
:
12
:
+ Add row
Crew
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Paramedic 1 (Attending) – No.
Designation
Name
Signature
No. 1
Paramedic 2 – No.
Designation
Name
Signature
No. 2
Other – No.
Designation
Name
Signature
No. 3
Other – No.
Designation
Name
Signature
No. 4
General Administration
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Vehicle Number
Station
Status
Hospital Number
Receiving Facility/Destination
UTM Code
Dispatch
Return
Patient Sequence
Base Hospital Name
Base Hospital Physician Name/No. (if patch)
Patch Log Number
Call Events
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Call Received
:
:
Crew Notified
:
:
Crew Mobile
:
:
Arrive Scene
:
:
Patient Contact
:
:
Depart Scene
:
:
Arrive Destination
:
:
Date of ACR Completion
/
/
Time of ACR Completion
:
Remarks - Disposition
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Remarks
Primary Problem
Problem Code
Sp Trans Code
Base Hospital Number
Disposition of Effects
Deceased
Obviously dead
DNR
BHP TOR
Pronounced by on scene physician
Physician/BHP Name (if pronounced/TOR)
CTAS Arrive Patient
CTAS Depart Scene
CTAS Arrive Destination
Warning Systems – To Scene
None
Emergency Systems
Warning Systems – To Destination
None
Emergency Systems
TOC (Transfer of Care) – Date
/
/
Time
:
Transfer of Care to
Receiving Staff
Family
Other (list):
1 – Patient Chart Copy
2 – Billing Office Copy
3 – Base Hospital Copy
4 – Ambulance Service Copy