EMS Patient Care Report (Non-Emergent Scheduled Transport)

ePCR/Run Number: [ePCR/Run Number] Date of Service: [Date of Service] Service Type: [Service Type] (Default: Non-emergent scheduled) Transport Pattern: [Single / Repetitive] Transport Purpose: [Dialysis / Wound care / Radiation / Clinic visit / Discharge / Other: [specify]] Level Billed: [BLS / ALS1 / ALS2] Unit/Crew: [Unit/Crew identifiers] Dispatch/Trip ID: [Dispatch or Trip ID]

Times and Mileage

• Unit notified: [Time]
• En route: [Time]
• Arrived pickup: [Time]
• Patient contact: [Time]
• Departed pickup: [Time]
• Arrived destination: [Time]
• Transfer of care complete: [Time]
• In service: [Time]
• Loaded mileage: [Loaded miles]
• Route deviations: [Rationale] (Only include if medically or operationally significant)

(If any time is estimated, document source, method, and when obtained.)

Patient Information

• Patient name: [Name]
• DOB: [DOB] Sex: [Sex]
• Facility MRN or Medicare ID: [Identifier] (If available)
• Pickup location: [Room/unit or address]
• Responsible party: [Name / Relationship / Contact] (If applicable)
• Facility contact at pickup: [Name / Role / Contact]
• Facility contact at destination: [Name / Role / Contact]
• Insurance type: [Medicare / Medicaid / Commercial / Self-pay / Unknown]
• Identifier verification method: [Face sheet / ID band / Verbal confirmation / Other] (Document if no face sheet provided)

Origin and Destination

• Origin type and name/address: [Facility/home type; name; full address]
• Destination type and name/address: [Facility type; name; full address]
• Nearest appropriate facility: [Yes / No] (If No, briefly explain why destination chosen)
• Repetitive transport criteria met: [Yes / No / N/A] (≥3 round trips in 10 days OR ≥1 round trip/week for ≥3 weeks)

Medical Necessity

(Document why ambulance transport is required instead of wheelchair van, stretcher van, or private vehicle. Select applicable contraindications and provide a patient-specific narrative. Do not use generic statements.)

• [Bed confinement] (Select only if all three elements documented below)
• [Inability to sit upright safely]
• [Requires stretcher positioning: [position/angle]]
• [Requires continuous oxygen: [device] at [L/min]]
• [Requires monitoring: [Pulse oximetry / Cardiac / BP intervals / Other]]
• [Requires skilled interventions during transport: [specify]]
• [Requires restraints: [type] for [clinical reason]]
• [Isolation precautions: [Contact / Droplet / Airborne / Neutropenic / Other]]
• [Severe pain with movement limiting safe seating: [describe]]
• [Bariatric constraints: [weight/width; equipment needs]]
• [High fall risk: [indicators]]
• [Other transport-limiting condition: [describe]]

Medical necessity narrative: [Patient-specific narrative describing limiting conditions, why alternative transport modes are contraindicated, and required positioning/monitoring/care during transport] (Use objective observations and/or reliable reports. Avoid boilerplate language.)

Bed confinement documentation: (All three required if claimed)

• Unable to get up from bed without assistance: [Yes / No]
• Unable to ambulate: [Yes / No]
• Unable to sit in a chair/wheelchair: [Yes / No]
• Supporting observations: [Transfer ability, trunk control, sitting tolerance, source of information]

(If any element is unknown or No, do not use bed confinement as the primary justification.)

ALS justification: [Link patient's condition to need for ALS-level capabilities] (Only include if billing ALS)

Subjective / Baseline

Transporting from [origin] to [destination] for [service].

• Relevant history impacting transport: [Diagnoses affecting transport such as mobility deficits, cardiopulmonary disease, wounds]
• Dialysis details: [Schedule/frequency; access type and location] (If applicable)
• Medications/allergies pertinent to transport: [List] (If unavailable, document "Requested / Not provided")
• Patient quote: "[Quote describing limiting symptoms]" (Only if provided and relevant)

Objective Assessment

• General appearance/distress: [Description]
• Mental status/orientation: [A&O status; baseline]
• Airway: [Patent / Compromised; adjuncts if present]
• Breathing: [Effort; breath sounds; baseline SpO2 on/off supplemental O2]
• Circulation/skin: [Color/temp/moisture; perfusion]
• Neurologic deficits affecting mobility: [Description or None]
• Skin integrity/positioning issues: [Wounds/pressure injuries; locations; dressing status]
• Lines/tubes/drains: [List requiring monitoring or securement]
• Vitals at pickup: [BP / HR / RR / SpO2 / Temp / Pain]
• Serial en-route vitals: [Times and values] (At least every 15 minutes if oxygen, monitoring, or instability risk present)
• Vitals at destination: [BP / HR / RR / SpO2 / Temp / Pain]
• Pertinent negatives: [Specific negatives supporting medical necessity decisions]

Mobility / Positioning / Safety

• Ambulation ability: [Independent / With assistive device / 1-assist / 2-assist / Unable]
• Transfer assistance required: [Independent / 1-assist / 2-assist / Mechanical lift / Unable]
• Wheelchair sitting tolerance: [Yes / No; minutes tolerated; limiting symptoms]
• Fall risk indicators: [Findings or screening tools used]
• Stretcher required due to: [Cannot sit upright / Requires supine / Unsafe transfers / Pain with sitting / Monitoring needs / Other]
• Transport position: [Supine / Semi-Fowler / Fowler / Lateral] at [angle if applicable]
• Securing method: [Standard 3-strap / 5-strap / Shoulder harness / Vacuum mattress / Bariatric cot / Other]
• Special positioning/bariatric equipment: [List or None]
• Pressure injury precautions: [Offloading devices; padding; repositioning frequency] (If applicable)
• Transfer equipment and personnel: [Stair chair / Slide board / Mechanical lift / Number of personnel]

Interventions / Transport Course

• Oxygen: [Device; flow L/min; titration changes; response]
• Monitoring used: [Pulse oximetry / Cardiac / NIBP intervals / Capnography / None]
• Procedures performed: [Description or None]
• Medications administered: [Name; dose; route; time; response] (If any)

Transport narrative: [Brief chronological narrative: condition at contact, tolerance of loading, en-route changes/interventions, condition at arrival vs baseline] (If no interventions: "No interventions required; monitoring as above; patient remained stable.")

Disposition / Handoff

• Receiving party: [Name, credential/role]
• Handoff method: [Verbal report / Written paperwork / Both]
• Patient condition at handoff: [Stable / Unchanged / Changes described]
• Last vitals: [BP / HR / RR / SpO2 / Temp / Pain]
• Property/documents transferred: [PCS / Face sheet / Medical packet / Med list / Personal belongings]

PCS / Certification

• Transport type: [Scheduled repetitive / Scheduled non-repetitive / Unscheduled]
• PCS on file: [Yes / No / Requested]
• If Yes: Date signed [Date]; Certifying clinician [Name, credentials] (Confirm within 60-day lookback and signed before service for scheduled repetitive)
• If No: [Reason absent; attempts to obtain]
• If non-physician certification: [Certifier role; employment relationship; confirmation of personal knowledge]

(PCS supports but does not prove medical necessity—clinical documentation must stand alone.)

RSNAT Prior Authorization

(Complete only for repetitive scheduled non-emergent transports)

• PA required: [Yes / No / First three round trips exempt]
• PA status: [Affirmative / Non-affirmative / Pending / N/A]
• Tracking number: [Number] (Required on claims)
• Authorized date range: [Start–End]
• Authorized trips: [Number]

Signatures

• Patient signature obtained: [Yes / No]
• If no patient signature: [Authorized representative name and relationship] (If no representative available: document incapacity reason, state no representative available, capture employee statement with name/role, obtain receiving facility verification)
• If signature refused: [Document refusal and circumstances]

Author Attestation

• Primary author: [Name, credentials]
• Electronic signature: [Date/Time]
• Partner/crew review: [Names/credentials] (If applicable)
• Addenda: [Entries with date/time/author] (Track separately; do not overwrite original)

(If information is missing because facility did not provide it, document "Requested / Not provided" with source and time. If clinically inapplicable, document "N/A." Do not auto-populate medical necessity language without patient-specific supporting facts. Limit inference to simple clinical interpretations from observed facts; do not infer bed confinement or monitoring needs without documented objective support.)