STATEMENT TOOL
Non-emergent medical necessity
Document the medical condition and reasons alternate transport is contraindicated.
Patient Medical Condition (Box 1 of PCS):
The Patient Can/Cannot Be Safely Transported by Other Means (Box 2 of PCS):
can
cannot
Reasons Why Alternate Transport Is Contraindicated (Box 3 of PCS):
Contractures
Non-healed fractures
Confusion
Comatose state
Moderate to severe pain on movement
Danger to self or others
IV medications required
Fluids are required
The patient is combative
A need or possible need for restraints
DVT requires elevation of a lower extremity
Medical attendant required
The patient requires oxygen and was unable to self-administer
Infection control precautions were required
Unable to tolerate the seated position
Hemodynamic monitoring required en route
Unable to sit in chair/wheelchair due to wounds
Cardiac monitoring required en route
Morbid obesity required additional handling
Orthopedic device required during transport
Patient is bed confined
Generate Narrative
Generated Statement
Use in medical necessity
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