| Entry ID | 185 |
|---|---|
| eOrder Submission Date | 04/24/2024 |
| eOrder Submission Time | 15:53 PM |
| Requester Information | |
| Ordering Facility | Providence St. Jude Plaza Radiation Oncology |
| Requester Department | Radiation Oncology |
| Requester Phone | 7144465632 |
| Requester Email | Email hidden; Javascript is required. |
| Service Needs Information | |
| Service Level | EMT Basic Life Support |
| Trip Type | Wait and Return |
| Bariatric Patient? | No |
| Ambulance Transfer Reason(s) |
|
| Trip Schedule Information | |
| Pickup Date | 04/25/2024 |
| Response Type | Scheduled Transport |
| Pickup Time | 07:20 AM |
| Appointment Time | 08:00 AM |
| Standing Order | Yes |
| Standing Order Details | Friday, April 26th 7:20am pick up for an 8am treatment. |
| Pickup Location Information | |
| Pickup Location | Providence St. Jude Medical Center |
| Pickup Location Department/Unit Name | 4109 |
| Pickup Location Patient Room/Bed No. | 4109 |
| Pickup Location Department Phone | 7144469000 ext 7520 |
| Drop Off Location Information | |
| Drop Off Location | Providence St. Jude Plaza Radiation Oncology |
| Drop Off Receiving Department/Unit Name | radiation oncology |
| Drop Off Receiving Department Phone | 714 446 5632 |
| Reimbursement Information | |
| Patient Information | |
| Patient Name | James Leiblic |
| Medical Record No. | 20015092064 |
| Patient Sex | Female |
| Patient Date of Birth | 02/07/1948 |
| Patient Age | 76 |
| Spoken Language | English |
| Interpreter Required? | No |
| Patient Medical Information | |
| Isolation Precaution | No |
| Medical Necessity Certification | |
| Is Patient Bed-confined? | Yes |
| Medical Needs During Transport | |
| Required Equipment and Care |
|
| Other Needed Equipment or Services | pain meds to be given |
| Accompanying Documents | Please upload accompanying transfer documents. |
| Order Submission Certification | |
| Signature | |
| eOrder Submission Date | 04/24/2024 |