Ministry of Health

and Long-Term Care

Confidential when completed Ambulance Call Report
Hospital Registration Number

Demographics
Service Name Service No. CACC/ACS Call Number Call Date
YYYY / MM / DD
Last Name First Name

Age Sex Weight (kg) Date of Birth Health Insurance Number Version
YYYY / MM / DD
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
Date of Occurence Time of Occurence Chief Complaint
YYYY / MM / DD HH : MM Positive for FREI

Incident History MOHLTC DNR Confirmation Number

Trauma Problem Site/Type

Location Type Mechanism

Relevant Past History Provided by: Patient Other:

Cardiac Stroke/TIA Seizure Psychiatric Cancer CNO

Previously Healthy
Respiratory Hypertension Diabetes Anaphylaxis Other (list below)

Details

Medications None Nitrates Insulin/Oral Diabetic Meds Phosphodiesterase Inhibitors

CNO ASA Blood thinner/Anticoagulants Salbutamol Furosemide

Other

Allergies NKA CNO Other – list below

Details

Treatment Prior to Arrival None EFRT Physician Fire Bystander CNO

Midwife Other Paramedic Nurse Police Self Other (list below)
Details

Cardiac Arrest Information Date Start Time

Arrest Witnessed By Bystander Trained Responder Paramedic Unwitnessed YYYY / MM / DD HH : MM

CPR Started By Bystander Trained Responder Paramedic None YYYY / MM / DD HH : MM

First Shock By Bystander Trained Responder Paramedic YYYY / MM / DD HH : MM

Physical Exam
General Appearance Skin Colour Skin Condition

Head/Neck Trachea - Midline Shifted -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

1881-45 (2017/01) © Queen’s Printer for Ontario, 2017 7530-4714

 Ministry of Health
and Long-Term Care
Confidential when completed Ambulance Call Report
Hospital Registration Number

Demographics
Service Name Service No. CACC/ACS Call Number Call Date
YYYY / MM / DD
Last Name First Name

Age Sex Weight (kg) Date of Birth Health Insurance Number Version
YYYY / MM / DD
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
Charge No Charge Billing Evaluation Payment Received
Patient Inter-Hospital Transfer In my professional medical opinion ambulance use was: Initials
Employer Home Care Essential: a medical/other necessity Disposition in Hospital Emergency
W.S.I.B. Homes for Special Care Non essential: not a medical necessity/other transport suitable Dept.
Refused treament and released
D.V.A. Nusing Home Patient Signature (medical practitioner/approved authority)
treated (observed) and released
D.N.D. Home for the Aged Admitted
Coroner Recipient General Morgue
Chargeable Welfare Welfare Assistance Transferred to another hospital
Basic Fee
Other Other Billed by Out Patient
Patient’s portion
O.P. Clinic
Charge for km over 40 Hospital/Clinic Ca. Clinic
DND/RCMP Social Insurance No.
Operator X-Ray
Other charge Other
Registration No. Hospital Code Other In-patient returning
Amount billed
In-patient discharged

1881-45 (2017/01) Billing Copy 7530-4714

 Call Number
Page of

Clinical Treatment/Procedures Results

Time Procedure Dose/Unit Route Pulse Resp. B/P Temp. Reading/ SpO2 EtCO2 GCS Pupils Pain Crew
HH : MM Code Rate Rate Sys/Dia Code R± L± Scale Mbr. No.

Remarks

Disposition of Effects
Receiving Staff Family Other (list):
Primary Problem Problem Code Sp Trans Code CTAS Arrive Patient

Deceased CTAS Depart Scene

Obviously dead DNR BHP TOR Pronounced by on scene physician
Physician/BHP Name (if pronounced/TOR) Date Time CTAS Arrive Destination
YYYY / MM / DD HH : MM
General Administration
Vehicle Number Station Status Hospital Number Receiving Facility/Destination

UTM Code Dispatch Return Patient Sequence Warning To Scene None Emergency Systems
Systems To Destination None Emergency Systems
Base Hospital Name Base Hospital Number Base Hospital Physician Name/No. (if patch) Patch Log Number

Call Events Call Received Crew Notified Crew Mobile Arrive Scene Patient Contact Depart Scene Arrive Destination TOC
HH : MM : SS HH : MM : SS HH : MM : SS HH : MM : SS HH : MM : SS HH : MM : SS HH : MM : SS HH : MM :SS
Paramedic 1 (Attending) No. Name Designation Signature No. 1

Paramedic 2 No. Name Designation Signature No. 2

Other Name Designation Signature No. 3

Other Name Designation Signature No. 4

Date of ACR Completion Time of ACR Completion 1 – Patient Chart Copy 2 – Billing Office Copy
YYYY / MM / DD HH : MM : SS 3 – Base Hospital Copy 4 – Ambulance Service Copy
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Station Codes Cardiac 22 Second Degree Block IV Procedures
Station # 51 Ischemic 23 Third Degree Block 340 IV Monitoring
00 53 Palpitations 30 Ventricular Fibrillation 341 IV Cannulation
01 54 Pulmonary Edema 31 Pulseless Ventricular Tachycardia 342 Lock
02 55 Post Arrest 32 PEA 345 Normal Saline
etc. 56 Cardiogenic Shock 33 Asystole 349 Other IV Solutions
57 STEMI 40 NSR 350 IV Cannulation Unsuccessful
Status Codes
58 Hyperkalemia 42 Paced Rhythm 351 Fluid Bolus
00 At Base
43 Junctional Rhythm 353 Blood Sampling
77 Mobile Non-Traumatic 44 Sinus Dysrhythmia 355 IV Discontinued (Intentional)
88 Standby Location 60 Non Ischemic Chest Pain 46 Other (Detail in Procedures) 356 IV Discontinued (Unintentional)
99 Maintenance 61 Abdominal/Pelvic/Perineal/ 358 Intraosseous Cannulation
Dispatch Priority Codes Rectal Pain Procedures Successful
1 Deferrable 62 Back Pain 010 Vital Signs 359 Intraosseous Cannulation
2 Scheduled Gastrointestinal 020 Patient Assessment Unsuccessful
3 Prompt 63 Nausea/Vomiting/Diarrhea 025 Blood Sampling-Glucose Determination 360 Blood/Blood Product
4 Urgent 100 Dressing Administration
8 Standby Musculoskeletal/Trauma 101 Control Bleeding 361 CVAD Access
9 Out of Service/Administration 66 Musculoskeletal 102 Arterial Tourniquet
67 Trauma/Injury 105 Immobilization-Head Miscellaneous Procedures
Return Priority Codes 110 Splint Other 366 Termination of Resuscitation –
1 Deferrable Obstetrical/Gynecological Medical
71 Obstetrical Emergency 111 Cervical Collar
2 Scheduled 112 Spinal Board 367 Termination of Resuscitation –
3 Prompt 72 Gynecological Emergency Trauma
73 Newborn/Neonatal 113 Spinal Immobilization Extrication
4 Urgent Device 370 Other Procedure
6 Transport of Deceased Patient Endocrine/Toxicological 114 Traction Splint (Detail in Procedures)
81 Drug/Alcohol Overdose 115 Adjustable Break Away Stretcher 372 Carboxyhemoglobin (SpCO)
Return Priority-No Transport 375 Emerg. Dialysis Disconnect
71 No Patient Found 82 Poisoning/Toxic Exposure 116 Lifting Chair
83 Diabetic Emergency 120 Suction 390 Transfer of Care – Crew to
72 Patient Refused Crew
73 Patient Deceased 84 Allergic Reaction 129 Oxygen – Filtered High Conc. Mask
85 Anaphylaxis 130 Oxygen – High Conc. Mask 400 Base Hospital Physician Patch
74 Patient in Police Custody 401 Receiving Hospital Notified
75 Transported by Other 86 Adrenal Crisis 131 Oxygen – Simple Face Mask
132 Oxygen – Nasal Cannula 402 BHP Patch Failure
Ambulance General and Minor (Detail in Results)
8 Standby 87 Novel Medications 133 Oxygen – Other
141 Oxygen – BVM 403 BHP Patch – No BHP Contact
9 Out of Service/Administration 88 Home Medical Technology 404 Coroner Notified
89 Lift Assist 142 Oxygen – Mechanical Ventilator
Special Transport Codes 144 Oxygen – Pocket Mask 405 Study Procedure
01 Pt. Meets Trauma Criteria 90 Inter-facility Transfer (Detail in Procedures)
91 Environmental Emergency 150 Extricate Patient – e.g., Remove from
02 No Trauma Bypass – small room where care cannot be 406 Non Dialysis – CVAD
Pt.Condition 92 Weakness/Dizziness/Unwell Disconnect
93 Treatment/Diagnosis & Return provided
03 No Trauma Bypass – 160 OB Delivery 407 Health Screening Tool
Hospital Refusal 94 Convalescent/Invalid/Return
Home 161 External Uterine Massage Medications
04 Pt. Meets Stroke Criteria 162 Placental Delivery 498 Acetaminophen
05 No Stroke Bypass – 95 Infectious Disease
96 Organ Retrieval/Transfer 163 Umbilical Cord Management 500 Adenosine
Pt. Condition 164 Apgar Score 502 Amiodarone
06 No Stroke Bypass – 98 Organ Recipient
99 Other Medical/Trauma (see 170 Oro/Nasopharyngeal Airway 503 Antibiotic
Hospital Refusal 180 Restrain Patient-Physical 504 ASA
07 Pt. Meets STEMI Criteria remarks)
190 Abdo/Chest/Back Thrusts 505 Atropine
08 No STEMI Bypass – Site/Type Codes 211 Symptom Assist Medication 525 Calcium Gluconate
Pt. Condition A Location (e.g., Assisted Pt. with own meds) 528 Dextrose D10W
09 No STEMI Bypass – 10 Head/Face/Ear/Scalp 231 Pt. Transported Supine 529 Dextrose D25W
Hospital Refusal 11 Eye 232 Pt. Transported Semi-Prone 530 Dextrose D50W
Pick-up Codes 12 Neck 233 Pt. Transported Prone 531 Diazepam
A Airport/Heliport 13 Shoulder 234 Pt. Transported Semi-Sitting 533 Dimenhydrinate
B Apartment/Condo. Building 14 Back/Flank 235 Pt. Transported Sitting 534 Diphenhydramine
C Construction Site 15 Chest 236 Ambulatory 536 Dopamine
D Medical Office/Clinic 16 Abdomen 237 Pt. Transported Lateral 540 Epinephrine 1:1,000
E Nursing Outpost 17 Pelvis 239 Infant Restraint Device 541 Epinephrine 1:10,000
F Factory/Industrial Site/ 18 Genitourinary Cardiac Arrest Procedures 550 Fentanyl
Railway/Dockyard 19 Buttocks/Perineum/Rectum 297 Therapeutic Hypothermia 551 Furosemide
G Hotel 20 Arm (Upper/Elbow/Forearm/ 298 Defibrillation – Pads On 560 Glucagon
H Hospital (Acute and Wrist) 299 Automated CPR Device 561 Glucose-Oral
Non- Acute) 21 Hand/Finger 562 Hydroxocobalamin
300 CPR
I Indoor Shopping Mall 22 Thigh 593 Lidocaine
23 Leg (Knee/Lower Leg/Ankle) 301 Rhythm Interpretation
J Jail/Prison 603 Midazolam
24 Foot/Toes 302 Cardioversion 604 Morphine
K Single Store/Strip Mall
25 Hip 303 Valsalva Manoeuver 610 Naloxone
L School/College/University
M Mining Site/Quarry 306 Defibrillation – Manual 615 Nitroglycerin
B Type 307 Defibrillation – Semi-Automated
N Long-Term Care Home 620 Oxytocin
30 Abrasion 308 Analyze – SAED
O Office Building 650 Salbutamol
31 Amputation 309 External Pacing
P Sports Facility/Arena 651 Sodium Bicarbonate
32 Avulsion 313 12-Lead Acquisition
Q Farm 682 Xylometazoline
33 Burn
R House/Town House 316 Return of Spontaneous Circulation 700 Other Drugs – Detail in
34 Blunt
S Street/Highway/Road Procedures
35 Crush Airway/Breathing Procedures
T Fairground/Park 701 Anaesthetic Eye Drops
36 Contusion 317 Return of Spontaneous Respirations
U Retirement Home 704 Ibuprofen
37 Penetrating/Perforation 318 Supraglottic/Alternate Airway
V Golf Course 706 Ketorolac
38 Possible Fracture/Dislocation 319 Supraglottic/Alternate Airway
W Water/Boat 708 Obidoxime
39 Laceration Unsuccessful
X Restaurant/Bar 710 Pralidoxime Chloride
40 Sprain/Strain 320 Needle Thoracostomy
Y Casino 711 Hydrocortisone
41 Paralysis/Paresthesia 321 Needle Thoracostomy Unsuccessful
Z Other (Describe in Remarks) 712 Sodium Thiosulfate
42 Other (Detail in Incident Hx) 322 Needle/Surgical 800-899 Study Drugs – Details
Problem Codes C Mechanism Cricothyroidotomy in Procedures
VSA 50 Assault 323 Needle/Surgical Cricothyroidotomy 900-999 User Defined
01 Cardiac/Medical 51 Drowning Unsuccessful
02 Traumatic 52 Electrocution 324 Nasotracheal Intubation Routes of Administration
53 Fall (Same Level) 325 Nasotracheal Intubation Unsuccessful AE Aerosol
Airway 326 Orotracheal Intubation BU Buccal
11 Obstruction 54 Fall from Height/Diving
55 Gunshot 327 Orotracheal Intubation Unsuccessful ET Endotracheal
(Partial/Complete) 328 ETT Suctioning IM Intramuscular
56 Hanging
Breathing 57 Machinery 329 Tracheostomy Tube Suctioning IN Intranasal
21 Dyspnea 58 MVC 331 Magill Forceps/Foreign Body Removal IO Intraosseous
24 Respiratory Arrest 59 Motorcycle/Recreational Vehicle 332 Magill Forceps/Foreign Body Removal IV Intravenous
60 Pedal Bicycle Unsuccessful NB Nebulized
Circulation 61 Pedestrian Struck 333 Extubation – Any Advanced Airway PO Oral
31 Hemorrhage 62 Sports (intentional) PR Rectal
33 Hypotension 63 Stabbing 334 Extubation – Any Advanced SL Sublingual
34 Suspected Sepsis 64 Fire/Explosion/Thermal Airway (Unintentional) SC Subcutaneous
Neurological 65 Smoke/Chemical Exposure 335 Needle Thoracostomy One-way Valve TO Topical
41 Stroke/TIA 66 Other (detail in Mechanism of Monitored
336 Respiratory System Eval. (ETCO2 and Paramedic Designation
42 Temp. Loss of Consciousness Incident Hx)
SAO2) 1 Student
43 Altered Level of Consciousness Rhythm Codes 2 EMA
44 Headache 337 ETT Confirmation
10 Sinus Tachycardia 338 SpO2 3 PCP
45 Behaviour/Psychiatric 11 PSVT/SVT/Atrial Tachycardia 4 ACP
46 Active Seizure 339 PEEP
12 Atrial Flutter 376 Electronic Control Device Removal 5 CCP
47 Paralysis/Spinal Trauma 13 Atrial Fibrillation
48 Confusion/Disorientation 380 Alternative Airway CTAS Codes
14 Ventricular Tachycardia 381 Alternative Airway – Unsuccessful
49 Unconscious 1 Resuscitation
20 Sinus Bradycardia 382 Airway Adjunct/Bougie
50 Post-ictal 2 Emergent
21 First Degree Block 383 CPAP 3 Urgent
384 CPAP - unsuccessful 4 Less Urgent
5 Non Urgent
0 Obviously Dead/TOR
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 Reference Information
1 2 3 4 5 6 7 8
Skin
Colour Condition
Flushed Dry 0 - 10 Numeric Pain Intensity Scale
Pale Clammy 0 1 2 3 4 5 6 7 8 9 10
Cyanosis Diaphoretic
Jaundice Unremarkable
Unremarkable No Mild Moderate Severe Worst
Pain Pain Pain Pain Possible Pain

Glasgow Coma Scale Pediatric Coma Scale

Eye Opening Verbal Response Motor Response Eye Opening Verbal Response Motor Response
4 Spontaneous 5 Orientated 6 Obeys commands 4 Spontaneous 5 Coos or babbles 6 Obeys commands
3 To Voice 4 Confused 5 Localize (pain) 3 To Speech 4 Irritable & constantly cries 5 Withdraws from touch
2 To Pain 3 Inappropriate words 4 Withdraw (pain) 2 To Pain 3 Cries to pain 4 Withdraws from pain
1 None 2 Incomprehensible sounds 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

APGAR Score Normal Pediatric Vital Signs

Parameter 0 1 2 Age Respiratory Rate Heart Rate

Appearance Blue or Pale Pink body with Completely pink 0 – 3 months 30 - 60 90 - 180
blue extremities
3 – 6 months 30 - 60 80 - 160
Pulse (BPM) 0 (absent) slow (<100) >100
6 – 12 months 25 - 45 80 - 140
Grimace Response None Some grimace Good grimace
1 – 3 years 20 - 30 75 - 130
Actitivity and
None, limp Some flexion Active, motion
Muscle Tone 6 years 16 - 24 70 - 110

Respiratory Effort absent <60 min Good, crying 10 years 14 - 20 60 - 90

APGAR performed at 1 & 5 minutes after delivery Systolic Blood Pressure (for children 1-10 yrs) > 90 + (2x age in years)
Don’t wait for APGAR to make decision on resuscitation Weight (kg) = (age x 2) + 10

Definition of Hypoglycemia
>2 years Glucometry <4.0 mmol/L
<2 years Glucometry <3.0 mmol/L

Aid to Capacity Evaluation (Record Details in ‘Remarks’ Section)

Indicate to whom this assessment refers if not the patient [e.g., parent, or substitute decision maker (SDM)]

Patient verbalizes/communicates understanding of clinical situation?

Yes No - Requires consideration of capacity
(e.g., what is wrong with you?)
Patient verbalizes/communicates appreciation of applicable risks? (e.g., what Yes No - Requires consideration of capacity
could happen if I don’t help you?)
Patient verbalizes/communicates ability to make alternative plan for care?
Yes No - Requires consideration of capacity
(e.g., what will you do once I leave?)

Responsible adult on scene Yes No

Refusal of Service – I have been advised that treatment and/or transportation is available immediately. I refuse such treatment and/or transportation to hospital
having been informed of the risks involved. I assume full responsibility arising out of such refusal.
Refus de service – On m’a avisé que je pouvais être traité ou transporté à l’hôpital immédiatement. Je refuse d’être traité ou transporté à l’hôpital. J’ai été
informé des risques auxquels cette décision m’expose. J’assume l’entière responsabilité de ce refus.
Patient/ Substitute decision maker (SDM) – print name and address / Patient/mandataire spécial (MS) – Nom et adresse en lettres moulées

If SDM, relationship to Patient / Si MS, relation avec le patient

Time Date Signature of Patient or SDM / Signature du patient ou du MS

HH : MM YYYY / MM / DD

I have advised this patient or SDM of the risks to the patient’s health that are involved.
J’ai avisé le patient ou le MS des risques de cette décision pour la santé du patient.
Time Date Attending Paramedic Signature

HH : MM YYYY / MM / DD

I was witness to the above-mentioned refusal and that the person has been informed of the risks involved.
J’ai été témoin du refus susmentionné et du fait que la personne a été informée des risques de ce refus.
Time Date Non Paramedic Witness Name Witness/Paramedic 2 Signature
Nom du témoin autre qu’un ambulancier paramédical Signature du témoin/d’un 2e ambulancier paramédical

HH : MM YYYY / MM / DD

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