| Entry ID | 11 |
|---|---|
| eOrder Submission Date | 01/20/2023 |
| eOrder Submission Time | 09:26 AM |
| Requester Information | |
| Ordering Facility | Providence St. Jude Medical Center |
| Title | Other |
| Other Title | ASI-Admin |
| Requester Department | ASI-Admin |
| Requester Phone | (310) 844-2092 |
| Requester Email | Email hidden; Javascript is required. |
| Service Needs Information | |
| Service Level | Nurse-Staffed Specialty Care Transport |
| Trip Type | One-Way |
| Bariatric Patient? | No |
| Ambulance Transfer Reason(s) |
|
| Trip Schedule Information | |
| Pickup Date | 01/20/2023 |
| 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. | B3 |
| Pickup Location Department Phone | (714) 555-1212 |
| Pickup Location Contact Name | Jane Doe |
| Drop Off Location Information | |
| Drop Off Location | Other |
| Other Drop Off Location Name | Hoag Hospital Newport Beach |
| Other Drop Off Address | 1 Hoag Drive Newport Beach, California 92663 Map It |
| Drop Off Receiving Department/Unit Name | ED |
| Drop Off Patient Room/Bed No. | B9 |
| Drop Off Receiving Department Phone | (714) 555-3333 |
| Drop Off Receiving Contact Name | ED Triage |
| Reimbursement Information | |
| Primary Insurance Carrier | Secure Horizons |
| Member ID No. | 123456 |
| Payor Authorized? | Yes |
| Payor Authorization No. | 123456 |
| Patient Information | |
| Patient Name | John Doe |
| Medical Record No. | 123456 |
| Patient Sex | Male |
| Patient Date of Birth | 02/18/1956 |
| Patient Age | 65 |
| Spoken Language | English |
| Interpreter Required? | No |
| Patient Medical Information | |
| Isolation Precaution | No |
| Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance | Post Chest Pain relived by nitro taken at 08:05 am today. |
| Medical Necessity Certification | |
| Is Patient Bed-confined? | No |
| Medical Needs During Transport | |
| Required Equipment and Care |
|
| Number of IV Drips | 0 |
| Other Needed Equipment or Services | Safety line established. |
| Accompanying Documents | Please upload accompanying transfer documents. |
| Order Submission Certification | |
| Signature | |
| eOrder Submission Date | 01/20/2023 |