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EMERGENCY MEDICAL AMBULANCE SERVICES MINISTRY OF HEALTH

“Wahai Tuhan kami berikanlah rahmat kepada kami dari sisi-Mu dan sempurnakanlah bagi kami petunjuk yang lurus dalam urusan kami (ini)”.

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DAILY AMBULANCE REPORT LOG

Email *

ESN *

DATE *

STATION * (non operational) support team may include PG support, logistic support or Admin support.

SHIFT *

STAFF * (Incharge, staff, delta )

MODE OF TRANSPORT *

Ambulance Reg * (BGXXXX)
(please state if other vehicle involve or used)

TIME
RECIEVE

TIME
ON MOBILE
*

TIME
ARRIVE LOCATION

*

TIME
LEAVE LOCATION
*

TIME
ARRIVE DESTINATION

*

PATIENTS DETAILS

Patient's Name
*

GENDER *

Date Of Birth
day/month/year (age)

*

BRUHIMS NUMBER (BNXXXX)
IDENTIFICATION CARD NUMBER (IC)
or PASSPORT NUMBER

*

Address *

Mukim *

DISTRICT *

CASE DETAILS

CATEGORY

*

TYPE OF TRAUMA

SUB-CATEGORY *

DISPOSITION *

DESTINATIONS *

PRIORITY *

CHIEF COMPLAINT *

CASE REPORT
* (AGE/GENDER, C/O-COMPLAINT OF, H/O-HISTORY OF, K/C-KNOWN CASE [allergies], O/A-ON ARRIVAL, O/E-ON EXAMINATION, MX-MANAGEMENT, DISPOSITION
(-approprite values(VITALSIGN)/findings should be stated properly)
(-state who produce the report at the end .....- SNPXXXX)

EPR (emas patient report) form

DAILY AMBULANCE REPORT LOG

Click Submit to finish.