Providence Ambulance eOrders

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Entry ID119
eOrder Submission Date10/03/2023
eOrder Submission Time09:47 AM
Requester Information
Ordering FacilityProvidence Mission Hospital Laguna Beach
TitleOther
Other Titledispatch
Requester Departmentdispatch
Requester Phone(310) 644-0500
Requester EmailEmail hidden; Javascript is required.
Service Needs Information
Service LevelNurse-Staffed Specialty Care Transport
Trip TypeRound Trip
Bariatric Patient?No
Ambulance Transfer Reason(s)
  • Services required not available at sending facility, patient being transferred for out-of-facility services but will remain an in-patient of sending facility.
Trip Schedule Information
Pickup Date10/03/2023
Response TypeScheduled Transport
Pickup Time12:30 PM
Appointment Time01:30 PM
Return Pickup Date10/03/2023
Return Pickup Time05:30 PM
Standing OrderNo
Pickup Location Information
Pickup LocationProvidence Mission Hospital Laguna Beach
Pickup Location Department/Unit Namemedsurge
Pickup Location Patient Room/Bed No.310
Pickup Location Department Phone(949) 555-5555
Drop Off Location Information
Drop Off LocationProvidence Mission Hospital Mission Viejo
Drop Off Receiving Department/Unit NameRADIOLOGY
Drop Off Receiving Department Phone(949) 123-4567
Reimbursement Information
Patient Information
Patient NameJASON DERULO
Patient SexMale
Patient Date of Birth01/01/1950
Patient Age83
Spoken LanguageEnglish
Interpreter Required?No
Patient Home Address123456 STREET
LAGUNA BEACH, 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

HEART FAILURE

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.
Medical Needs During Transport
Required Equipment and Care
  • Oxygen
  • Cardiac Monitoring
  • IV Fluid Administration Monitoring
Number of IV Drips1
Accompanying DocumentsPlease upload accompanying transfer documents.
Order Submission Certification
Signature
eOrder Submission Date10/03/2023