Sample Run Sheet

You will need to use the front and back side of a standard size 8 1/2 x 11 sheet of paper for all data shown below

Your Ambulance Service

Patient Name:_______________________________Run/Vehicle No:______________Date:___________

Street Address:__________________________________________________________________________

City:______________________________________State:____________________Zip:________________

Phone:_(_______)________________________Date of Birth:______________________Male / Female

Race: W - B - O Social Security Number:_________________________________

Medicare:________________________________Medicaid:_______________________________________

Employer:______________________________Address:__________________________________________

City:_________________________State:_____Zip:_______________ Phone:_____________________

Insurance Company:_________________________ Address:_____________________________________

City:_________________________State:_____Zip:_______________ Phone:_____________________

Policy #_______________ Group #______________

Responsible Party: (if other than patient):______________________________________________

Relationship to Patient: Self - Spouse - Child - Other

Billing Address (if other than above )___________________________________________________

City:_____________________________________State:____________________Zip:_________________

Work Related: Y-N Accident:Y-N MVA: Y-N ALS vehicle: Y-N Round Trip: Y-N

Transported From: [ Residence [ Scene [ Nursing Home Other_______________________________________

Transported To:____________________________________________Loaded Miles:_________________

Chief Complaint/probable diagnosis_______________________________________________________

Past History:____________________________________________________________________________

Check all Special Services Performed and abnormal conditions

__IV Therapy	__Medication	__Spinal Immob	__CPR
__Bleeding control	__Defib/Cardiovert	__Suctioning of Airway	__EKG
__Maintain Airway	__Oxygen Therapy	__LOC Monitored	__Bedridden
__Stabilize Poss FX	__Treat Shock __MAST	__TreatCVA/Drugs/poison	__CPR
___________% Pulse OX	_______Glucose reading	____/____Blood Pressure	__Restraints

NON-EMERGENCY Transports
To justify ambulance transport we ***MUST MUST MUST*** prove that the patient could not be transported by Automobile/Van/Wheelchair if these were available.

___	Patient could not sit for duration of transport
___	Patient required stabilization in a certain position to reduce pain/possible injury
___	Other reason ambulance required
	IF ANY BLOCKS ABOVE WERE CHECKED, SPECIFICALLY AND EXACTLY EXPLAIN BELOW

The undersigned agrees to: Œ Release all information for filing claims; If assignment is accepted, reimbursement is directly to the ambulance company; Ž if Medicare, Medicaid, Insurance rejects due to medical necessity, eligibility, or other reasons, that the patient is responsible for payment; if legal/collection agencies are required, patient is responsible for fees.

Patient/Responsible Party___________________________________

Medic 1___________________________________ EMT-P EMT-I EMT-B (circle one)

Medic 2___________________________________ EMT-P EMT-I EMT-B (circle one)

Medic 3___________________________________ EMT-P EMT-I EMT-B (circle one)

Check all that apply -- required in Alabama -- helpful in all states

1A	Bedridden
2A	Accidental injury home/nursing home
3A	Accidental injury car
4A	Patient in shock
5A	Oxygen used and/or heart monitor
6A	Transported by stretcher
7A	Fracture to hip, leg ,knee, trunk (same day as ambulance trip)
8A	Hospital lacks facility (patient admitted to 2nd hospital)
9A	Rectal bleeding
1B	Myocardial infarction
2B	Possible CVA
2C	Mental retard
3B	Black out passed out
4B	Laceration of head
5B	Dead on arrival (DOA) at hospital
6B	Died enroute to hospital
7B	Unresponsive or coma
8B	Quadriplegia
9B	Stroke same day ambulance service
9C	Paralysis

Proposed HCFA Diagnoses Listed on Federal Register
(check all that apply)

01a	Abdominal Pain, unspecified site
01b	Abdominal Pain, generalized
01c	Abdominal Pain, specified site
02	Abnormal Electrocardiogram (EKG)
03	Asphyxiation and Strangulation
04	Backache, Unspecified
05a	Burns, unspecified degree
05b	Burns, first degree
05c	Burns, blisters, second degree
05d	Burns, full-thickness skin loss, third degree
05e	Burns, deep necrosis of underlying tissue, deep third degree
05f	Burns, deep necrosis with loss of body part
06	Cardiac Arrest
07	Chest Pain, Unspecified
08	Coma
09	Contracture of Multiple Joints
10	Convulsions
11	Delirium, acute
12	Dead on Arrival (Cause Unknown; death occurring in less than 24 hours from onset of symptoms)
13	Drowning
14	Drug Overdose; Unspecified Drug or Medicinal Substance
15	Effects of Lightning
16	Electrocution and nonfatal affects caused by electric current
17	Food Poisoning
18	Head Injury, closed
19	Head Injury, open
20	Hemorrhage of Gastrointestinal tract, unspecified
21	Hemorrhage, unspecified
22	Hypothermia
23	Injuries, multiple
24	Injury to Elbow, Forearm and Wrist
25	Injury to Face and Neck
26	Injury to Hand
27	Injury to Hip and Thigh
28	Injury to Knee, Ankle, Leg and Foot
29	Injury to Shoulder and Upper Arm
30	Injury to Trunk
31	Instantaneous Death
32	Joint Pain, multiple
33	Open Wound, Unspecified Eye Ball
34	Other Artificial Opening (e.g., presence of chest tubes)
35	Other Specified Problems Influencing Health Status (e.g. bed-confined)
36	Pelvis Pain, female
37	Pelvis Pain, male
38	Pelvis Stiffness
39	Poisoning, unspecified noxious substance eaten as food
40	Respiratory Arrest
41	Respiratory Distress
42	Shock
43	Smoke Inhalation, Symptomatic
44	Stroke
45	Transient Alteration of Awareness
46	Unconscious
47	Unspecified Complication of Labor and delivery
48	Wound Disruption (Dehiscence)
I C D 9 C O D E S	These codes werelisted on the Federal Register (Oct 97) in HCFA proposed legislation for ambulance service codes, but not yet enacted into regulations. Use when applicable, but we do not agree that this is an adequate list - thus, these are in no stretch of the imagination the only ones that we will use. We have search engines that can use key words / phrases / approximate words, etc. and search a (vast) diagnosis database for an appropriate group of codes and descriptions. Therefore, we will to search and select from key works in the narrative on the state run sheet. Write down what you found, what was wrong, what happened, what you did, etc. and we will be able to extract ICD codes.