Providence Ambulance eOrders

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Entry ID155
eOrder Submission Date03/20/2024
eOrder Submission Time20:44 PM
Requester Information
Ordering FacilityProvidence St. Jude Medical Center
TitleRegistered Nurse
Requester DepartmentER
Requester Phone1231233333
Requester EmailEmail hidden; Javascript is required.
Service Needs Information
Service LevelEMT Basic Life Support
Trip TypeOne-Way
Bariatric Patient?No
Ambulance Transfer Reason(s)
  • HMO Authorized Service
Trip Schedule Information
Pickup Date03/23/2024
Response TypeScheduled Transport
Pickup Time12:00 PM
Standing OrderNo
Pickup Location Information
Pickup LocationProvidence St. Josseph Hospital Orange
Pickup Location Department/Unit NameER
Pickup Location Patient Room/Bed No.ER BED 2
Pickup Location Department Phone3106440500
Pickup Location Contact NameTEST TEST
Drop Off Location Information
Drop Off LocationProvidence St. Josseph Hospital Orange
Drop Off Receiving Department/Unit NameTEST
Drop Off Patient Room/Bed No.TEST
Drop Off Receiving Department Phone3106440500
Reimbursement Information
Primary Insurance CarrierMEDICARE
Member ID No.TEST
Payor Authorized?No
Patient Information
Patient NameTEST TEST TEST
Patient SexFemale
Patient Date of Birth03/12/2024
Patient Age1
Spoken LanguageEnglish
Interpreter Required?No
Patient Home Address1 Mission Viejo Rd
Mission Viejo, California 92691
United States
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Patient Medical Information
Isolation PrecautionNo
Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance

TEST INPUT

Medical Necessity Certification
Is Patient Bed-confined?Yes
Ambulance Medical Necessity Reason(s)
  • Dementia severe altered mental status decreased LOC combative lethargic or comatose.
Medical Needs During Transport
Required Equipment and Care
  • Airway Monitoring
Accompanying DocumentsPlease upload accompanying transfer documents.
Order Submission Certification
Signature
eOrder Submission Date03/20/2024