Non-Emergency Coding Clinic - PWW Media Inc. · Attendee License Agreement Once you (Licensee)...

Non-Emergency Coding Clinic Claim Documents

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2016-2017 Program Materials

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Entire Agreement

Background Information

The transport examples in the coding clinics were performed by “Mickey Mouse Ambulance,” a fictional, private, non-profit ambulance service serving the fictional “Magic Kingdom.” Mickey Mouse Ambulance has 6 vehicles, with six crew teams, as identified below. Within the Magic Kingdom are the fictional cities of Atlantica, Radiator Springs, Frontierland, Tomorrowland, Neverland, Fantasyland, Monstropolous, and Zootopia, as outlined on the attached map. The facilities and locations (other than private residences) where trips originate or end are listed below, and also appear on the map. In this Coding Clinic, we are deciding how to code these transports and to which payer the transports should be billed. In cases where the transport is not billable to Medicare (based on the information available for review) we must decide what steps to take.

Ambulance Crew Member Signature Log

Unit # Crew Member Name

Signature Specimen Certification Level

Certification Number

1

Peter Pan Peter Pan EMT-Paramedic P-00755

Tinker Bell Tinker Bell EMT-Paramedic P-00377

2

Donald Duck Donald Duck EMT-Paramedic P-00031*

Daisy Duck Daisy Duck EMT-Basic B-00014

3

Sebastian Mon Sebastian Mon EMT-Paramedic P-00823*

Flounder Ing Flounder Ing EMT-Basic B-00046

4

Hans Southern Hans Southern EMT-Basic B-00369

Kristoff Anderson Kristoff Anderson EMT-Basic B-00123

5

Celia Weelia Celia Weelia EMT-Basic B-00598

James P. Sullivan Sully EMT-Basic B-00623

6

Dopey Dwarf Dopey Dwarf EMT- Basic B-00765

Happy Dwarf Happy Dwarf EMT-Paramedic P-00978

* Advanced paramedic scope of practice includes: arterial line monitoring, ventilator operations and the following medication administrations: blood and blood products, antibiotic infusions, and heparin.

Assisted Living Dialysis Center

Community Hospital

Zootopia 99918

Urgent Care Clinic

General Hospital

Neverland 99915

Holy Spirit Hospital & Select LTACH

Medical Center Apartment

Fantasyland 99916

Power Plant

Radiator Springs 99912

Frontierland 99913

Tomorrowland 99911

©2016, Page, Wolfberg & Wirth, LLC

Golden SNF

Outpatient Center/ Freestanding Clinic

Monstropolous 99917

County Jail

Hotel Magic SNF

Good Samaritan Hospital

MAP OF MAGIC KINGDOM

End of the Road SNF

List of Facilities and Locations

Medical Center Trauma Center and 1,000 Bed Hospital 1 Magic Kingdom Way, Fantasyland 99916 General Hospital 500 Bed Hospital w/ ER 10 Atlantica View Rd., Neverland 99915 Good Samaritan Hospital 200 Bed Hospital w/ ER 14 Randall Dr., Monstropolus 99917 Holy Spirit Hospital 150 bed hospital w/ separate specialty center 100 14th St. Radiator Springs, 99912 Community Hospital 25 Bed Hospital and ER 6467 Race St., Zootopia, 99918 Select LTACH 10 Bed SNF, 20 Bed Hospital inside Holy Spirit Hospital (4th Floor) 100 14th St. Frontierland, 99913 Golden SNF 75 Bed SNF, with Hospice Care 2319 Sock Dr., Monstropolous, 99917 End of the Road SNF 100 Bed SNF & Hospice Care 17 Main St. Fantasyland, 99916

Magic SNF 100 Bed SNF and Assisted Living Facility 1501 Oswald St., Fantasyland, 99916 Assisted Living Personal Care Home, no skilled services offered 42 Wallaby Way, Atlantica, 99914 Dialysis Center Dialysis Center (not hospital based) 7878 Creek Run Road Frontierland 99913 Outpatient Center/Freestanding Clinic Ambulatory surgery, diagnostic services, Freestanding ED services Highway 15 North, Frontierland 99913 Apartment Complex 150 Units 500 Dwarf Street, Fantasyland 99916 Power Plant 2320 Atlantica View Rd., Neverland 99915 Hotel 99 Olaf St., Zootopia, 99918 Urgent Care Clinic 2004 Incredible Dr., Tomorrowland, 99911 County Jail 1001 Acorn Way, Monstropolous, 99917

Magic Kingdom - Response Determinants and Dispatch Codes Response/Transport Priority Alpha – BLS Cold (Non-emergency) Bravo – BLS Hot Charlie – ALS Cold (Non-emergency) Delta – ALS Hot Echo – ALS Hot Dispatch Codes 001 – Cardiac/ Heart Problems (ALS) 002 – Respiratory/Breathing Problems (ALS) 003 – Fall – greater than 10 feet (ALS) 004 – Fall – less than 10 feet (BLS) 005 – Animal Bite – with other symptoms (ALS) 005 – Animal Bite – no other symptoms (BLS) 006 – Fracture – with other symptoms (ALS) 007 – Fracture – without other symptoms (BLS) 008 – Gunshot/Stab Wound – dangerous body part/bleeding not under control (ALS) 009 – Gunshot/stab wound – not dangerous body part/bleeding under control (BLS) 010 – Hemorrhage/Bleeding – dangerous body area or 2° symptoms (e.g. vomiting/pain) (ALS) 011 – Hemorrhage/bleeding – not dangerous body area or minor bleeding (BLS) 012 – Seizure Activity (ALS) 013 – Altered Mental State – other symptoms (ALS) 014 – Altered Mental State – no other symptoms (BLS) 015 – Sick Person, Man Down, unknown status (ALS) 016 – Sick Person, known status, minor condition (BLS) 017 – CVA/Stroke (ALS) 018 – Mass/Multiple Trauma (ALS) 019 – Fever – no other symptoms (BLS) 020 – Pain – no other symptoms < 4/10 on pain scale (BLS) 021 – Pain – other symptoms, >4/10 on pain scale (ALS) 022 – Choking – alert, awake, no other symptoms (BLS) 023 – Diabetic Problems (BLS) 024 – Eye Problem (BLS) 025 – Headache (BLS) 026 – Syncope/Vertigo (BLS) 027 – Pregnancy/Childbirth (BLS) 028 – Overdose (ALS) 029 – Psychiatric/Suicidal (BLS) 030 – Heat/Cold Exposure (BLS) 031 – Burns 1st degree or less than 10% of body (BLS) 032 – Burns 2nd or 3rd degree or greater than 10% of body (ALS) 033 – Non-emergency Interfacility Transfer / Palliative Care / Discharge 034 – Welfare Check (BLS) Approved: Mickey Mouse, MD, CEO Date: 7/1/2015

Magic Kingdom Department of Health - Approved ALS Drugs

1. Activated Charcoal 2. Adenosine 3. Albuterol 4. Amiodarone 5. Aspirin 6. Atropine 7. Calcium Chloride 8. Diazepam 9. Dilaudid 10. Diltiazem 11. Diphenhydramine HCL 12. Epinephrine 13. Fentanyl 14. Furosemide 15. Glucagon 16. Intravenous solutions (Dextrose, NaCl, Lactated Ringer’s) 17. Lidocaine 18. Lorazepam 19. Magnesium Sulfate 20. Midazolam 21. Morphine 22. Naloxone HCL (Narcan) IV 23. Nitroglycerin 24. Ondansetron 25. Sodium bicarbonate

+ EMT-B scope of practice includes transport of a patient with an existing IV lock, O2 administration, BGL check, and Narcan administration IM.

Signed:

Walt Disney, MD Medical Director, Magic Kingdom Department of Health

Effective Date: 7/1/2015

abc360 Coding Clinic – Checklist – Non-Emergency

Run # Med

ical

Nec

essit

y Do

cum

ente

d? (Y

/N)

Reas

onab

lene

ss M

et?

(Y

/N)

Tran

spor

t to

Cove

red

Dest

inat

ion?

(Y

/N)

Mile

age

Reco

rded

? (Y

/N)

PCS

Crite

ria M

et?

(Y/N

)

Sign

atur

e Va

lid fo

r Cla

im

Subm

issio

n? (Y

/N)

Coding Comments

201 NE

202 NE

203 NE

204 NE

205 NE

206 NE

207 NE

Run 201-NE


Mickey Mouse Ambulance

Patient Care Report

RUN NUMBER: 201 NE PATIENT NAME: Charlotte La Boeff DATE OF SERVICE: 8/14/16

Times Response Information Mileage

CALL RECV’D 11:00:02

DISPATCH CODE 004- Fall BLS

TO SCENE 0.0

DISPATCH 11:35:14

RESPONSE PRIORITY Alpha

ON SCENE 0.0

ENROUTE 11:35:56

LOCATION

Magic SNF, 1501 Oswald St., Fantasyland, 99916

ENROUTE TO DEST. 0.0

ON SCENE 11:46:15

TRANSPORTED TO

Medical Center, 1 Magic Kingdom Way, Fantasyland, 99916

AT DEST. 7.0

DEPART SCENE 12:10:34

TRANSPORT PRIORITY Alpha

TOTAL LOADED

MILEAGE 7.0

ARRIVE DEST. 12:25:18 DISPATCH COMMENTS: Multiple ground level falls today Demographic

NAME Charlotte La Boeff

DOB 12/08/1943

AGE 72

WEIGHT 125 lbs

ADDRESS 1307 Hunt St. Fantasyland, 99916

SEX F

Initial Information CHIEF

COMPLAINT Pain, weakness all over body PT FOUND Lying on couch

MEDICAL HX Falls, cancer

MEDICATIONS Multiple

ALLERGIES NKDA

IMPRESSION Weakness

Narrative

Initial BLS Assessment: GCS: 15 (4/5/6); Skin: Warm, Normal; Eyes: PEARL; General Exam Finding: Weakness Unit 5 responded to call for fall. Arrived on scene at above location to find 72 YOF lying on a couch in the resident rec room at the facility, with facility staff reporting that pt. fell multiple times today. Pt. is in the assisted living wing of the facility, not receiving skilled care. No obvious injuries noted – pt. denies pain to lower extremities. Pt. denies LOC, or head/neck injury. Full head to toe assessment reveals no head/neck/spine injuries. Pt. reports feeling weak for previous two days and when she tries to walk, “my legs just give out.” Nursing staff from facility recommended pt. be transported to hospital for evaluation. Pt. reports that SNF facility is cold and she has trouble sleeping at night such that she is weak and tired during the day. Pt. found to have low SpO2 level (80%), so O2 administered at 4 LPM. After several minutes, SpO2 increased to 100%. Pt. denies prior history of respiratory problems. Pt. denies SOB, chest pain, or other symptoms.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP

EXAM (NEURO, RR, CV, ABD, SKIN)

TREATMENT (O2, MED, PIV, EXTRICATION)

11:50:15 80% BLS Assessment O2 4-LPM (NC) - hypoxia

12:14:35 125/78 102 20 90%

Crew Information

Lead Celia Weelia CERT# B-00598

LEVEL B

SIGNATURE

Celia Weelia

Driver James P. Sullivan CERT# B-00623

LEVEL B

SIGNATURE Sully

Mickey Mouse Ambulance Signature/Claim Submission Authorization Form

Patient Name: Charlotte La Boeff Transport Date: 8/14/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*

This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.


Describe the circumstances that make it impractical for the patient to sign: ALOC

I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.

Authorized representatives include only the following individuals:

Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient

X Eli La Boeff 8/14/16 Eli La Boeff, spouse

Representative Signature Date Printed Name of Representative

I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Mickey Mouse Ambulance now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Mickey Mouse Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Mickey Mouse Ambulance any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Mickey Mouse Ambulance. I authorize Mickey Mouse Ambulance to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Mickey Mouse Ambulance and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Mickey Mouse Ambulance, now, in the past, or in the future. I also authorize Mickey Mouse Ambulance to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.

If the patient signs with an “X” or other mark, a witness should sign below.

X Patient Signature or Mark Date Witness Signature Date

Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time: A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.

A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the

authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.

X Signature of Crewmember Date Printed Name and Title of Crewmember

B. Receiving Facility Representative Signature

The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.

X_____________________________________ ____________ ____________________________________________________ Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Complete this section only if the patient is physically or mentally incapable of signing.

SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing.

NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.

SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Complete this section only if: (1) the patient was physically or mentally incapable of signing, and

(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.

Physician Certification Statement for Non-Emergency Ambulance Services

Section 2 - Medicare Definition of “Medical Necessity” for Ambulance Transportation:

Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.

The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Nonemergency transportation by ambulance is appropriate if either:

o The beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or,

o If his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.

Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.

For a beneficiary to be considered bed-confined, the following criteria must be met:

o The beneficiary is unable to get up from bed without assistance. o The beneficiary is unable to ambulate. o The beneficiary is unable to sit in a chair or wheelchair.

The medical necessity definition above appears exactly as it is contained in 42 C.F.R. § 410.40.

Section 3 - Certification

I certify that the medical necessity requirements set forth above for ambulance services are met.

8/15/16

Signature Date

____________Jacques Facilier_, MD_____________________________________ Printed Name and Credentials of Physician* or Healthcare Professional (REQUIRED)

*For scheduled, repetitive transports, this form must be signed by the patient’s attending physician. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.

For non-repetitive or unscheduled transports, this form may be signed by one of the following if the signature of the attending physician cannot be obtained:

● Registered Nurse ● Discharge Planner ● Nurse Practitioner ● Physician Assistant ● Clinical Nurse Specialist

Section 1 – Patient Information

Patient Name: Charlotte La Boeff Date of Birth: 12/08/1943 Transport Date: 8/14/16

Run 202-NE



Patient Care Report

RUN NUMBER: 202 NE PATIENT NAME: Rudy Oldgye DATE OF SERVICE: 8/1/2016


CALL RECV’D

19:59:12 (7/31/2016)

DISPATCH CODE 033 - Interfacility

TO SCENE

DISPATCH

05:46:16 (8/1/2016)

RESPONSE PRIORITY Charlie

ON SCENE

ENROUTE 05:46:12

LOCATION

Good Samaritan Hospital, 14 Randall Dr. Monstropolous, 99917


ON SCENE 06:03:56

TRANSPORTED TO

Medical Center, 1 Magic Kingdom Way, Fantasyland 99916

AT DEST. 4.0


TRANSPORT PRIORITY Charlie

TOTAL LOADED

MILEAGE 4.0

ARRIVE DEST. 06:32:17 DISPATCH COMMENTS: Cardiac patient – requires cath lab services Demographic

NAME Rudy Oldgye

DOB 03/05/1939

AGE 77

WEIGHT 196 lbs

ADDRESS 200 Lakefront Ave., Frontierland, 99913

SEX M


COMPLAINT Cardiac Catheterization PT FOUND Ambulating in room

MEDICAL HX

Arthritis, HTN, Cardiac stent, MI, CAD, Hyperlipidemia, DM- II

MEDICATIONS Not listed

ALLERGIES Sulfa

IMPRESSION Cardiac monitoring required

Narrative

Unit 6 responded to request for NE transfer for cath lab services not available at origin. Patient had recent catheterization, but some of the occluded vessels were unable to be opened. Initial plan was to treat medically, and an additional catheterization would later be attempted. Pt. continued to experience symptoms and was admitted with negative enzymes so the plan is to take him to the cath lab for second attempt to reestablish flow. Pt. denies any distress, and has stable vitals, O2 saturation at 99%. Pt. transferred self to stretcher without assistance. EKG shows Sinus Rhythm with 1st degree block and occasional PVCs. Heart Sounds = S1, S2, without murmurs or gallops noticed. GCS=15, patient remains free of distress during transport. IV remains intact without edema or leaking. Upon arrival at destination facility, pt. unloaded from ambulance and transported to cath lab, where pt. self- transferred to bed without assistance. Bedside report given to RN. Assessment: Airway: Patent; Breath Sounds: Clear, Equal; LOC: A&Ox4; Circulation: Cap refill less than 2 seconds; CNS: Neuro intact; Head: Assessed with no abnormalities; Upper extremities: Assessed with no abnormalities; Lower extremities: Assessed with no abnormalities; Skin: Normal, elastic, moist, smooth

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP



PTA IV – other healthcare professional 20 G

06:07 150/90 76 18 99% LS = clear, equal, bilateral EKG – 1st Degree AV Block

Crew Information

Lead Happy Dwarf CERT# P-00978

LEVEL P

SIGNATURE

Happy Dwarf

Driver Dopey Dwarf CERT# B-00765

LEVEL B

SIGNATURE Dopey Dwarf


Patient Name: Rudy Oldgye Transport Date: 8/1/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*


This is a sample o


Describe the circumstances that make it impractical for the patient to sign:




X Representative Signature Date Printed Name of Representative



X Rudy Oldgye 8/1/16 Patient Signature or Mark Date Witness Signature Date

Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time: A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.

A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.










Good Samaritan Hospital

Electronic Ambulance Certification Form Patient Name (Last) Oldgye (First) Rudy Transport Date: 8/1/16 Patient DOB: 03/05/1939 Transport To: Medical Center, 1 Magic Kingdom Way, Fantasyland 99916 Patient requires cardiac catheterization services not available at origin hospital. Patient is being transferred to nearest appropriate facility with these services. Is the Patient Bed confined by Medicare (CMS) regulations? Yes No If yes, state condition or diagnosis for bed confinement: If no, can the patient be transported by wheelchair van? Yes No If no, list appropriate medical conditions which necessitate transport by ambulance and make all other means of transport contraindicated based on patient’s safety and health. (Supporting documentation for any conditions listed must be maintained in the patient’s health record). Patient requires constant cardiac monitoring due to partial blocked cardiac artery and need for catheterization services. Pt. is unstable, and could suffer an acute cardiac event at any time. I certify that the above information is true and correct based on my evaluation of this patient, to the best of my knowledge and professional training. I understand that this information will be used by the ambulance service transporting this patient to satisfy CMS requirements, for purposes of determining medical necessity for ambulance services. Electronically signed by: Date/Time: Emperor Kuzco, PAC 8/1/16 / 05:30

Patient Demographic Information

Reason for Transfer (Explain)

Medical Necessity for Ambulance

Certification

Run 203-NE



Patient Care Report

RUN NUMBER: 203 NE PATIENT NAME: Percival McLeach DATE OF SERVICE: 7/31/16



DISPATCH CODE 033 Interfacility

TO SCENE 0.0

DISPATCH 17:55:58


ON SCENE 4.3

ENROUTE 17:58:09

LOCATION

General Hospital, 10 Atlantica View Rd., Neverland 99915


ON SCENE 18:15:45

TRANSPORTED TO

Holy Spirit Hospital, 100 14th St. Radiator Springs, 99912

AT DEST. 9.9



TOTAL LOADED

MILEAGE 5.6

ARRIVE DEST. 20:08:13 DISPATCH COMMENTS: Interfacility transfer – liver transplant Demographic

NAME Percival McLeach

DOB 04/13/1951

AGE 65

WEIGHT 187 lbs

ADDRESS 200 Magic Drive, Neverland, 99915

SEX M


COMPLAINT Liver transplant PT FOUND In hospital bed

MEDICAL HX

Diabetes, hypertension, Hepatic- liver failure, Gastric reflux

MEDICATIONS Attached

ALLERGIES NKDA

IMPRESSION Hemodynamic monitoring required

Narrative

Unit 5 was initially dispatched for routine BLS non-emergency transfer for higher level of care for liver transplant. Upon arrival, crew met with RN for a report, who noted the patient has an indwelling arterial line. The BLS crew advised RN they were not able to transport patient without higher trained Paramedic, and contacted dispatch and try to locate higher trained personnel. I was then dispatched to assist, and I arrived on scene approximately 30 minutes later. Upon my arrival, I received a complete summary of the patient, including a past complaint of shortness of breath, with led to a diagnosis of hydrothorax. Pt. had pleural chest tube placed, and 4 liters of fluid was withdrawn about 1 week ago. The pt. became acutely hypotensive, and was admitted to ICU, and acute liver disease was diagnosed. Pt. also reported a recent (unintended) 50 lb. weight loss in past 6 months. Assessment revealed: Chest: Lungs CTA bilaterally, no wheeze, rales, or rhonchi; RR: 20-24, with no cough, with pleural chest tube located on right side, clamped by RN for transport. Tube was set to gravity drain via Pleuravac system. No fluid is noticed in the tube, but old, dark blood was observed in the Pleuravac. Cardiac: EKG reveals sinus tachycardia without ectopy. Abdomen: Significant distension of the abdomen noticed, and pt. denies discomfort; Skin: Warm, dry; Extremities: Thin, weak. Pt. is unable to stand or ambulate on his own since this admission into ICU (per nurse) but previously was active (per pt.). Left brachial artery line is patent – draws and flushes easily. Dressing is clean, clear, and intact. Left femoral triple lumen PICC line is currently capped. Treatments while enroute: Continuous monitoring of cardiac rhythm, BP, SpO2, arterial line, and chest tube. Upon arrival at destination, report given to receiving RN. Unit 5 crewmembers accompanied patient in transport, with Celia Weelia driving, and James P. Sullivan accompanying me in the patient compartment. End of narrative: Sebastian Mon, EMT-P.

Treatment Log

TIME

B/P

HR

RR

SPO2 ETCO2

TEMP



18:45 93/60 102 20 96% GCS=15 (4/5/6) EKG: ST

19:22 89/62 100 24 94%

Crew Information

Lead Sebastian Mon CERT# P-00823

LEVEL P

SIGNATURE

Sebastian Mon

Driver Celia Weelia CERT# B-00598

LEVEL B

SIGNATURE Celia Weelia

Additional James P. Sullivan CERT# B-00623 LEVEL B SIGNATURE Sully


SECTION I – GENERAL INFORMATION

Patient’s Name: Percival McLeach Date of Birth: 4/13/51

Transport Date: (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)

Origin: General Hosptial Destination: Holy Spirit Hospital

Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO

Closest appropriate facility? YES NO If no, why is transport to more distant facility required?

If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility: liver transplant

If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:______________________________________________

SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires

the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:

Cardiac monitoring, arterial central line in place, liver transport required with hemodynamic monitoring required enroute

2) Is this patient “bed confined” as defined below? Yes No To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair

3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:

*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records

Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement

Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints

DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer

Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport

Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds

Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient

Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport

Other (specify) Pleuravac, chest tube, arterial line – higher level care required during transport

SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows:

7/31/16 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for

transports performed more than 60 days after this date). Clara Belle Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.)



Patient Name: Percival McLeach Transport Date: 7/31/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*


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Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but

furnished other care, services, or assistance to the patient X Representative Signature Date Printed Name of Representative



X Percival McLeach 7/31/16 Patient Signature or Mark Date Witness Signature Date

Describe the circumstances that make it impractical for the patient to sign: Name and Location of Receiving Facility: Time:

A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by Mickey Mouse Ambulance.

A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)

My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.










Run 204-NE



Patient Care Report

RUN NUMBER: 204 NE PATIENT NAME: Arlo Apatosaurus DATE OF SERVICE: 10/3/16


CALL RECV’D

DISPATCH CODE 033 – BLS Transfer

TO SCENE 283410.5

DISPATCH 09:34:15


ON SCENE 283415.6

ENROUTE 09:35:47

LOCATION

Dialysis Center, 7878 Creek Run Road Frontierland 99913


ON SCENE 09:45:57

TRANSPORTED TO

915 Oak St., Tomorrowland, 99911

AT DEST. 283430.3



TOTAL LOADED

MILEAGE 14.7

ARRIVE DEST. 10:12:56 DISPATCH COMMENTS: Dialysis patient (T/TH/SA); PCS on FIle Demographic

NAME Arlo Apatosaurus

DOB 12/03/1950

AGE 65

WEIGHT 275 lbs

ADDRESS 915 Oak St., Tomorrowland, 99911

SEX M


COMPLAINT Dialysis PT FOUND In bed

MEDICAL HX HTN, diabetes, ESRD

MEDICATIONS Unknown

ALLERGIES None

IMPRESSION Post-dialysis transfer

Narrative

Unit 4 was dispatched to above location for transport of 65 yom to private residence post dialysis treatment. Pt. presented in supine position in reclined dialysis chair, awaiting our arrival. Pt. was A&O x4, receiving oxygen. Pt. was secured to the stretcher with rails up and straps applied because of general weakness and fall risk. Patient has a medical history that includes hypertension, ESRD, diabetes. Pt. vitals were noted below. Pt. was transported without incident to private residence where he was left to the care of himself. Pt. was left in hospital style bed in the living room on the first floor.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP



09:48 128/68 72 16 97% GCS=15 (4/5/6)

Crew Information

Lead Hans Southern CERT# B-00369

LEVEL B

SIGNATURE

Hans Southern

Driver Kristoff Anderson CERT# B-00123

LEVEL B

SIGNATURE Kristoff Anderson



Patient’s Name: Arlo Apatosaurus Date of Birth: __12/3/1950_________

Transport Date(s):8/3/16 – 10/3/16 (PCS is valid for round trips on this date and for all repetitive trips)

Origin: Residence Destination: Dialysis Center



If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:




Pt. is bed bound

2) Is this patient “bed confined” as defined below? Yes No

To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair

3) Can this patient safely be transported by car or wheelchair van (i.e., seated without monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:









Other (specify)

SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL

I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Ralph C. Reilly, MD 8/1/2016 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for

transports performed more than 60 days after this date). Ralph C. Reilly, MD Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner

Run 205-NE



Patient Care Report

RUN NUMBER: 205 NE PATIENT NAME: Bing Bong DATE OF SERVICE: 7/22/16



DISPATCH CODE 033 – Interacility Transfer

TO SCENE

DISPATCH 13:27:28


ON SCENE

ENROUTE 13:31:59

LOCATION

Magic SNF, 1501 Oswald St., Fantasyland, 99916


ON SCENE 14:05:00

TRANSPORTED TO

End of the Road SNF, 17 Main St. Fantasyland, 99916

AT DEST. 236868.0



TOTAL LOADED

MILEAGE 1.0

ARRIVE DEST. 14:37:03 DISPATCH COMMENTS: Pt. on low dose morphine drip Demographic

NAME Bing Bong

DOB 08/09/1947

AGE 68

WEIGHT 215 lbs

ADDRESS 18 Wagon Way, Fantasyland 99916

SEX M


COMPLAINT Transfer for end of life care PT FOUND Lying in bed

MEDICAL HX HTN, Renal Failure, Dementia, Lung Cancer

MEDICATIONS No current medications recorded

ALLERGIES NKDA

IMPRESSION Transfer for hospice care

Narrative

Unit 2 responded to above location for interfacility transport of patient requiring IV morphine administration and monitoring. Pt. found lying supine in bed, A&Ox2. Pt. was diagnosed with end-stage cancer and has elected hospice benefits. Patient has been at origin SNF for 2 years, and is no longer in a Part A stay. Origin SNF does not provide hospice services, and is being transferred for end of life care. Pt. was moved to stretcher via draw sheet method and secured with 2 straps. Pt. denies SOB, dizziness. Pt. is transported with O2 at 15 lpm via NRB. Assessment: HEENT, PEARL, no JVD, no tracheal deviation, equal chest rise/fall, L/S clear, equal, ABD is soft/non-tender in all 4 quadrants, pelvis is stable and intact. Upper and lower extremities have PMS, but contractures and weakness. Pt. is unable to tolerate sitting position, and is unable to ambulate, or get up from bed. Pt. meets the Medicare bed confined requirement. Pt. was transported in a position of comfort to End of the Road SNF, and remained stable during transport. No additional Morphine was required, due to short distance transport. Upon arrival, pt. was transferred to Bed 501 by draw sheet method and transfer of care given to LPN for further care. Signature obtained from Minnie Mouse, as representative of sending facility, due to patient’s inability to sign.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP



PTA Morphine drip

14:09 140/75 80 12 100% GCS = 14 (6/4/4) O2 15 LPM (NRB)

14:35 Monitor morphine drip

Crew Information

Lead Donald Duck CERT# P-00031

LEVEL P

SIGNATURE

Driver Daisy Duck CERT# B-00014

LEVEL B

SIGNATURE Daisy Duck


Section 2 - Medicare Definition of “Medical Necessity” for Ambulance Transportation:

Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.

The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Nonemergency transportation by ambulance is appropriate if either:

o The beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or,

o If his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.

Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.

For a beneficiary to be considered bed-confined, the following criteria must be met:

o The beneficiary is unable to get up from bed without assistance. o The beneficiary is unable to ambulate. o The beneficiary is unable to sit in a chair or wheelchair.

The medical necessity definition above appears exactly as it is contained in 42 C.F.R. § 410.40.

Section 3 - Certification

I certify that the medical necessity requirements set forth above for ambulance services are met.

Minnie Mouse 7/22/16

Signature of Physician* or Healthcare Professional Date Signed

Minnie Mouse, RN Printed Name and Credentials of Physician* or Healthcare Professional (REQUIRED)

*For scheduled, repetitive transports, this form must be signed by the patient’s attending physician. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.

For non-repetitive or unscheduled transports, this form may be signed by one of the following if the signature of the attending physician cannot be obtained:

● Registered Nurse ● Discharge Planner ● Nurse Practitioner ● Physician Assistant ● Clinical Nurse Specialist

Section 1 – Patient Information

Patient Name: Bing Bong Date of Birth: 08/09/1947 Transport Date: 7/22/16


Patient Name: Bing Bong Transport Date: 07/22/2016 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*


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Describe the circumstances that make it impractical for the patient to sign: ALOC, dementia, confusion, A&Ox2



Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance

services) but furnished other care, services, or assistance to the patient

X Minnie Mouse 7/22/16 Minnie Mouse, RN Representative Signature Date Printed Name of Representative

















Attestation Statement - Ambulance Crew Members

Name of Patient: Bing Bong Run Number/DOS: 205 NE/ 7/22/16

“I, Donald Duck [print full name of the crewmember that signed the PCR], hereby attest that the PCR dated 7/22/16 [date of service] accurately reflects signatures/notations that I made in my capacity as the treating Paramedic [insert specific crewmember level of certification (EMT-B, EMT-I, Paramedic, etc.)] when I treated and/or transported the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Donald Duck

Signed

Donald Duck, EMT-P

Printed Name

7/31/16

Date

Run 206-NE



Patient Care Report

RUN NUMBER: 206 NE PATIENT NAME: Destiny Whale DATE OF SERVICE: 7/17/2016



DISPATCH CODE 033 - Discharge

TO SCENE 266186.0

DISPATCH 18:33:51


ON SCENE

ENROUTE 18:35:35

LOCATION

Community Hospital, 6467 Race St., Zootopia, 99918


ON SCENE 18:43:35

TRANSPORTED TO

Apartment Complex, 500 Dwarf Street, Apt. 2C Fantasyland 99916

AT DEST. 266187.0



TOTAL LOADED

MILEAGE 0.0

ARRIVE DEST. 19:56:33 DISPATCH COMMENTS: Demographic

NAME Destiny Whale

DOB 4/15/49

AGE 67

WEIGHT 210 lbs

ADDRESS 500 Dwarf Street, Apt. 2C Fantasyland 99916

SEX F


COMPLAINT Status Post Chest Pain PT FOUND In bed

MEDICAL HX Diabetes

MEDICATIONS None recorded

ALLERGIES None

IMPRESSION Transfer

Narrative

Unit 1 dispatched for ALS non-emergency transport for 67 yof status post chest pain. Pt. was admitted 7/10/16, and is now being discharged due to being complaint/symptom free. Upon arrival at pt. room, pt. is found to be A&Ox3 GCS=15. Pt. was lying semi-fowlers in hospital bed, and was assisted off bed and onto stretcher and secured with straps and railings x2. Patient was safely loaded into ambulance and assessed. Vitals determined to be w/n/l for her, and rest of exam was unremarkable. Pt. had equal chest rise and fall and abdomen was soft and non-tender x4. Pt. had positive PMS to all 4 extremities, but with weakness in legs leaving her unable to safely walk on her own without assistance from personnel. Pt. was brought back to her residence at BLS level, because pt. had weakness to lower extremities leaving her unable to sit safely during transport or support herself. Pt. was assisted off stretcher at lobby of apartment complex. Pt. stated she wished to stay in lobby with her sister and neighbor, and did not want to be taken to her apartment at the moment. Pt. signed that she would be staying in her own care with her sister and neighbor.

Treatment Log

TIME

B/P

HR RR

SPO2 ETCO2

TEMP



19:19 116/64 68 18 ALS assessment – normal A&Ox4

19:35 112/62 66 16 GCS = 15 (6/5/4)

Crew Information

Lead Peter Pan CERT# P-00755

LEVEL P

SIGNATURE

Peter Pan

Driver Tinker Bell CERT# P-00377

LEVEL P

SIGNATURE Tinker Bell


Patient Name: Destiny Whale Transport Date: 7/10/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*


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Describe the circumstances that make it impractical for the patient to sign: cardiac problem



Patient’s legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance

services) but furnished other care, services, or assistance to the patient

X Charity Whale 7/10/16 Charity Whale, sister

Representative Signature Date Printed Name of Representative



















Patient’s Name: Destiny Whale Date of Birth: ___4/15/49________

Transport Date: 7/17/2016 (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)

Origin: Community Hospital Destination: Residence 500 Dwarf Streetr, Apt. 2C



If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:




Weakness, difficulty ambulating

2) Is this patient “bed confined” as defined below? Yes No

To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair

3) Can this patient safely be transported by car or wheelchair van (i.e., seated, withouy monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:









Other (specify)

SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL

I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Fergus King 7/17/2016

Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for

transports performed more than 60 days after this date). Fergus King, MD Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner

Client: Mickey Mouse Ambulance

Trip ID #: 206 NE

Patient: Destiny Whale

Date of Service: 7/17/16

From: Community Hospital, 6467 Race St., Zootopia, 99918

To: Apartment Complex, 500 Dwarf Street, Apt. 2C Fantasyland 99916

Loaded Miles: 13.5

Directions Plotted: 8/17/16 15:59

Source: Mileage calculated from Mapquest on Import

Instruction Distance Unit Depart 6467 Race St., towards Rte 30. 0.4 Miles Take entrance ramp to Rte 30 North 0.1 Miles Merge onto Route 83/322 8.7 Miles Follow signs for Rte/. 322 East 1.3 Miles Exit at Fantasyland Exit/ Middle Rd 2.4 Miles Follow Middle Rd. to Dwarf St. 0.1 Miles Turn left onto Dwarf Rd., destination is ½ mile on right 0.5 MIles

Run 207-NE



Patient Care Report

RUN NUMBER: 207 NE PATIENT NAME: Flash E. Pants DATE OF SERVICE: 7/1/2016



DISPATCH CODE 034 – Welfare Check (BLS)

TO SCENE 0.0

DISPATCH 14:58:01


ON SCENE 1.0

ENROUTE 14:58:54

LOCATION

250 Ivy Lane, Zootopia, 99918


ON SCENE 15:02:08

TRANSPORTED TO

Community Hospital, 6467 Race St., Zootopia, 99918

AT DEST. 6.3


TRANSPORT PRIORITY Bravo

TOTAL LOADED

MILEAGE 5.3

ARRIVE DEST. 15:23:33 DISPATCH COMMENTS: Welfare check – patient possibly involved in MVA and fled Demographic

NAME Flash E. Pants

DOB 11/25/1939

AGE 76

WEIGHT 164 lbs

ADDRESS 250 Ivy Lane, Zootopia, 99918

SEX M


COMPLAINT Knee pain PT FOUND On couch

MEDICAL HX Unknown

MEDICATIONS None reported

ALLERGIES NKDA

IMPRESSION

Narrative Unit 3 was advised by dispatch that Unit 1 was dispatched to the scene of a single vehicle MVA. Per dispatch, single occupant driver was reported to have been driven away from the scene by bystanders, and his SUV was found partially over the side of the roadway. Police and Unit 1 remained on scene, and Unit 3 was dispatched to perform a welfare check (along with PD) at driver’s home. Unit 3 arrived at patient’s home to find P.O. Judy Hopps already on scene. Pt. found conscious, in mild distress, sitting on a chair, watching t.v. Pt. recounted the events of the accident to Unit 3 personnel and P.O. Hopps. Pt. denied LOC, and initially refused care. Pt. agreed to be seen at ED for full evaluation, but chose POV for transport. P.O. Hopps offered to take pt. in her squad car. EMS provided assistance, while pt. tried to ambulate. When pt. was unable to navigate through the house and onto the porch, pt. agreed that ambulance transport would be preferred. Pt. stated he experienced significant pain (rated 7/10) while trying to make his way through the house. Pt. admitted to EMS that he was not wearing a seat-belt at the time of the crash, and the reason he fled was because he has an expired license and was scared he would be in trouble. Upon assessment, pt. presented with slight hypertension, with GCS =15, skin normal, warm, and dry. Head, neck and back were negative to pain on palpation, and pt. demonstrated full spinal ROM on request, without difficulty. Facial structures intact, with tenderness reported to left cheekbone. Clear lung sounds bilaterally to auscultation, with equal chest wall expansion. Pelvis intact to tilt and compression. Left hip rated 4/10 on pain scale, left knee rated 7/10. Minor 2 cm abrasion noted to shins bilaterally, and 3 cm abrasion noted to left thigh, and full thickness laceration to left middle finger. Minor pain reported to right wrist, and knuckle of right hand, with minor swelling and pain (rated 2/10). Pt. denies use of ASA or blood thinners. Pt. injuries determined to be conducive with description of the accident and MOI. Pt agreed to go to Community Hospital. Pt. moved to ambulance, moderate wounds dressed, and wrist splinted. P.O. Judy Hopps accompanied pt. to hospital to be able to continue to take information and statement from pt. regarding accident.

Treatment Log

TIME

B/P

HR

RR

SPO2 ETCO2

TEMP



15:05 155/78 68 16 100% ALS assessment (findings above)

15:10 GCS = 15 (6/5/4) Wound care bandaging, splinting

15:17 155/86 64 16 GCS=15 (6/5/4) enroute

15:27 155/76 65 16 100% At destination

Crew Information

Lead Sebastian Mon CERT# P-00823

LEVEL P

SIGNATURE

Sebastian Mon

Driver Flounder Ing CERT# B-00046

LEVEL B

SIGNATURE Flounder Ing


Patient Name: Flash E. Pants Transport Date: 7/1/16 Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mickey Mouse Ambulance provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*


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X Representative Signature Date Printed Name of Representative




Describe the circumstances that make it impractical for the patient to sign: immobilized right wrist, recent MVA victim Name and Location of Receiving Facility: Community Hospital, Zootopia Time: 15:25




X Flounder Ing 7/1/16 Flounder Ing Signature of Crewmember Date Printed Name and Title of Crewmember



X_____Fergus King________________ 7/1/16 Fergus King, MD

Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative






Non-Emergency Coding Clinic - PWW Media Inc. · Attendee License Agreement Once you (Licensee)...

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