Providence Ambulance eOrders

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Entry ID118
eOrder Submission Date10/03/2023
eOrder Submission Time09:20 AM
Requester Information
Ordering FacilityProvidence Mission Hospital Mission Viejo
TitleOther
Other TitleDispatcher
Requester DepartmentER
Requester Phone(310) 644-0500
Requester EmailEmail hidden; Javascript is required.
Service Needs Information
Service LevelEMT Basic Life Support
Trip TypeOne-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 Date10/03/2023
Response TypeScheduled Transport
Pickup Time11:30 AM
Standing OrderNo
Pickup Location Information
Pickup LocationProvidence Mission Hospital Mission Viejo
Pickup Location Department/Unit NameER
Pickup Location Patient Room/Bed No.BED 8
Pickup Location Department Phone(949) 500-4124
Pickup Location Contact NameDALTON DEAN
Drop Off Location Information
Drop Off LocationProvidence Mission Hospital Laguna Beach
Drop Off Receiving Department/Unit NameBHU
Drop Off Receiving Department Phone(949) 111-1111
Reimbursement Information
Patient Information
Patient NameJohn Doe
Patient SexMale
Patient Date of Birth01/01/2023
Patient Age23
Spoken LanguageEnglish
Interpreter Required?No
Patient Home Address1 Mission Viejo Rd
Mission Viejo, California 92679
United States
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Patient Medical Information
Isolation PrecautionNo
Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance

suicidal ideations, 5150 hold

Medical Necessity Certification
Is Patient Bed-confined?No
Ambulance Medical Necessity Reason(s)
  • Other.
Medical Needs During Transport
Required Equipment and Care
  • Patient Restraints (5150 Patient)
Accompanying DocumentsPlease upload accompanying transfer documents.
Order Submission Certification
Signature
eOrder Submission Date10/03/2023