Providence Ambulance eOrders – Ambulance Transport Order Portal

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Entry ID	104
eOrder Submission Date	09/26/2023
eOrder Submission Time	14:03 PM
Requester Information
Ordering Facility	Providence St. Jude Medical Center
Title	Other
Other Title	Ambulance Manager
Requester Department	ED
Requester Phone	(310) 844-2092
Requester Email	Email hidden; Javascript is required.
Service Needs Information
Service Level	EMT Basic Life Support
Trip Type	One-Way
Bariatric Patient?	No
Ambulance Transfer Reason(s)	Services required not available at sending facility, patient being discharged and admitted to another facility.
Trip Schedule Information
Pickup Date	09/26/2023
Response Type	Next Available - Patient Ready Now
Standing Order	No
Pickup Location Information
Pickup Location	Providence St. Jude Medical Center
Pickup Location Department/Unit Name	ED
Pickup Location Patient Room/Bed No.	B2
Pickup Location Department Phone	(714) 555-1212
Pickup Location Contact Name	John Doe
Drop Off Location Information
Drop Off Location	Other
Other Drop Off Location Name	Res
Other Drop Off Address	100 East Chapman Avenue Orange, California 92866 Map It
Drop Off Receiving Department/Unit Name	Home
Drop Off Receiving Department Phone	(714) 555-1111
Drop Off Receiving Contact Name	Pt Wife
Reimbursement Information
Primary Insurance Carrier	Medicare
Member ID No.	123456789
Payor Authorized?	No
Patient Information
Patient Name	John Smith
Medical Record No.	123456
Patient Sex	Male
Patient Date of Birth	10/12/1946
Patient Age	56
Spoken Language	English
Interpreter Required?	No
Patient Home Address	100 E Chpman Ave Orange, California 92866 United States Map It
Patient Medical Information
Isolation Precaution	No
Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance	Post CVA. TEST CALL>
Medical Necessity Certification
Is Patient Bed-confined?	Yes
Ambulance Medical Necessity Reason(s)	Unable to maintain erect sitting position in a chair for time needed for transport. Unable to sit in a chair or wheelchair due to Grade II or greater decubitis ulcers on buttock. Medicated and needs EMT monitoring during transport. Suffers from paralysis such as Hemi Semi Quad or contractourers. Condition is such that use of any other transportation method would endanger patients health.
ICD-10 #1	123.1
Medical Needs During Transport
Required Equipment and Care	Airway Monitoring
Accompanying Documents	Please upload accompanying transfer documents.
Order Submission Certification
Signature
eOrder Submission Date	09/26/2023