Medical Necessity

Patient is being transferred for ***REPLACE ME (specific services required) unavailable at Origin Facility.***
Transport by ambulance was required because patient has ***REPLACE ME (functional limitations, continuous monitoring needs, IV drips, oxygen requirements, altered mental status, instability, or clinical risk that prevents safe transfer by POV/wheelchair van).***

This transport met ***BLS OR ALS*** medical necessity due to:***

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Dispatch

ProMed Ambulance Company Unit ***Unit #*** was dispatched to ***Origin Facility*** for a patient being transferred to ***Destination Facility***.
The unit responded ***EMERGENT/NON-EMERGENT***, without lights or sirens, with Crew Members.

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Complaint

On arrival at the origin facility, found ***Age-year-old Gender*** patient ***REPLACE ME (position / location: lying in bed, semi-Fowler’s, etc.)***.
Patient is ***fully alert, alert to verbal, alert to painful stimuli, unresponsive***.
Patient complains of ***Chief Complaint***, which began at ***Enter Onset Time***, with progression: ***worsening/improved/unchanged***.

Nursing staff report: ***REPLACE ME (brief but medically relevant handoff including abnormal labs, treatments ongoing, physician orders, reason for transfer)***.

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History

Patient has a Past Medical History of ***REPLACE ME (PMH)***.
Patient is allergic to ***REPLACE ME (Allergies or NKDA)***.
Additional relevant history from staff includes ***REPLACE ME (recent treatments, baseline mobility, changes from baseline, etc.)***.

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Assessment

Patient found ***REPLACE ME (appearance, distress level, position)***.
Mental status: ***REPLACE ME (A&Ox4, confused, lethargic, disoriented)***.
Airway: ***REPLACE ME***.
Breathing: ***REPLACE ME (quality + rate)***.
Circulation: ***REPLACE ME (skin signs, perfusion, pulse quality)***.
Mobility: ***REPLACE ME (unable to ambulate, weakness, fall risk, pain, medical restrictions)***.
Abnormal findings: ***REPLACE ME***.
If applicable, 12-lead: ***REPLACE ME (baseline rhythm + pertinent interpretation)***.

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Rx / Treatments

Procedures Performed:

• ***REPLACE ME (IV/IO confirmation, cardiac monitoring, oxygen therapy, glucose check, airways, splinting, etc.)***

Medications Administered:

• ***REPLACE ME (drug, dose, route, response)***

If patient arrived with existing treatments ***(ex: insulin drip, pressors, antibiotic infusions)***:

Patient transferred with ongoing therapy of ***REPLACE ME***, which required continuous ALS monitoring.

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Transport

Patient was ***REPLACE ME (sheet-lift, stand-pivot assist, 2–3 person assist, etc.)*** onto the stretcher due to ***REPLACE ME (weakness caused by, fall risk, pain, instability).***
Patient placed in position of comfort and secured with straps and rails.
Patient loaded into the ambulance and secured.
Unit then went enroute to Destination Facility for ***REPLACE ME (specific specialty care: ICU, Cath Lab, Stroke, Trauma, Oncology, Surgery, etc.)***.

Patient was monitored throughout transport and ***REPLACE ME (remained stable / improved / exhibited changes)***.

On arrival, patient was transported into ***Room Number***.
Patient moved to bed ***lifted into the bed using a draw sheet, using stand and pivot*** and bed rails raised.
Verbal report given to ***Receiving Nurse Name***, and care transferred.
Unit cleared the facility and returned to service.

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Exceptions

***REPLACE ME (Delays, equipment issues, safety concerns, unusual conditions, patient behavior, med control involvement, etc.)***

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END