Case Review Request Form

This form is to be used by individual paramedics seeking a case review. Paramedic services, hospitals, and other organizations are to use the Organization Case Review Request form. Please do NOT enter any patient personal health information or identification into this form.

Call Date (*)

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Call Number (*)

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Paramedic Service (*)

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EHSN(*)

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Name(*)

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Email(*)

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Call Summary (Provide a synopsis of the call, including patient presentation, differential diagnoses and assessments done to them rule in or out, and care provided.)(*)

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Reason for the review request (What specific information are you interested in learning about the patient’s condition, and how will this improve care for future patients.)(*)

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Is this call under any type of review? (*)

YES NO

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Please note that (i) correspondence related to this case review will be via the ACE Tool, which your service leaders have access to; and (ii) as part of the review a QPS Specialist may ask you further questions and/or provide feedback on improving patient care.

Paramedic Case Review Request

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