Emergency Medical Care Information Template
ADVERTISEMENT
1Doctor _______________________________________ DOS______________________ Diagnosis __________________
Pt Name _________________________________ PHN ___________________________ DOB _____________________
Time called ____________________ time arrived _________________________ Call in code ______________________
Consult or visit fee code ______________start time _____________ end time ______________ (
)
represents the first 1/2 hour
Referring doctor is required if billing a consult _______________________________________ (full name and Pract # pls)
__________________________________________________________________________________________________
Emergency care may be applicable for time spent after initial assessment, or in replace of initial assessment, billable per half hour
until you leave for the transport.
81 __________ to ___________
81 __________ to ___________
82 __________ to ___________
82 __________ to ___________
______ cardiac arrest
______ cardiac arrest
_______ anaphylaxis
_______ anaphylaxis
______ Respiratory arrest
______ Respiratory arrest
_______ dysrhythmia
_______ dysrhythmia
Other _____________________
Other _____________________
_______ hyper/hyperglycemia
_______ hyper/hyperglycemia
__________________________
__________________________
_______ hyper/hypotensive
_______ hyper/hypotensive
________ ACLS protocols
________ ACLS protocols
_______ hypoxia
_______ hypoxia
________ bagged / ventilated
________ bagged / ventilated
_______ sepsis
_______ sepsis
________ cardioversion
________ cardioversion
_______ seizures
_______ seizures
________ catheter insertion
________ catheter insertion
_______ shock
_______ shock
________ central line
________ central line
_______ trauma
_______ trauma
________ CPR
________ CPR
Other: ____________________
Other: ____________________
________ infusion
________ infusion
__________________________
__________________________
________ intubated
Systems Monitored:
Systems Monitored:
________ intubated
_______ cardiovascular
_______ cardiovascular
________ IV meds
________ IV meds
_______ respiratory
_______ respiratory
________ O2
________ O2
_______ neurological
_______ neurological
________ transfusion
________ transfusion
_______ musculoskeletal
_______ musculoskeletal
Other:
Other:
_______ metabolic
_______ metabolic
__________________________
__________________________
Other: ________________________
Other: ________________________
__________________________
__________________________
______________________________
______________________________
__________________________
__________________________
______________________________
______________________________
____________________________________________________________________________________________________________
In transport: Left at ________________ (time) from ___________________ (place). Arrived at ________________ )time)
_______________(place). Traveled via ________________________________(ambulance, plane, boat etc) = 84 x _______________
____________________________________________________________________________________________________________
Emergency care may be applicable for time spent after arrival and before hand over, billable per half hour.
81 __________ to ___________
81 __________ to ___________
82 __________ to ___________
82 __________ to ___________
______ cardiac arrest
______ cardiac arrest
_______ anaphylaxis
_______ anaphylaxis
______ Respiratory arrest
______ Respiratory arrest
_______ dysrhythmia
_______ dysrhythmia
Other _____________________
Other _____________________
_______ hyper/hyperglycemia
_______ hyper/hyperglycemia
__________________________
__________________________
_______ hyper/hypotensive
_______ hyper/hypotensive
________ ACLS protocols
________ ACLS protocols
_______ hypoxia
_______ hypoxia
________ bagged / ventilated
________ bagged / ventilated
_______ sepsis
_______ sepsis
________ cardioversion
________ cardioversion
_______ seizures
_______ seizures
________ catheter insertion
________ catheter insertion
_______ shock
_______ shock
________ central line
________ central line
_______ trauma
_______ trauma
________ CPR
________ CPR
Other: ____________________
Other: ____________________
________ infusion
________ infusion
__________________________
__________________________
________ intubated
________ intubated
Systems Monitored:
Systems Monitored:
_______ cardiovascular
_______ cardiovascular
________ IV meds
________ IV meds
_______ respiratory
_______ respiratory
________ O2
________ O2
_______ neurological
_______ neurological
________ transfusion
________ transfusion
_______ musculoskeletal
_______ musculoskeletal
Other:
Other:
_______ metabolic
_______ metabolic
__________________________
__________________________
Other: ________________________
Other: ________________________
__________________________
__________________________
______________________________
______________________________
__________________________
__________________________
______________________________
______________________________
Continuing care may be payable for the entire time spent with the Pt from the time of arrival to the hand over.
Add 1205 / 6 / 7 from ___________________ to _________________ x ___________ units
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical