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IFT Guide

​TIME LINE

  • Crew gets paged

  • Crew assigned

  • Pick up ambulance

  • Pick up patient

  • Drop off patient

  • Return to station.

  • Complete paperwork

  • Complete truck duties

  • Complete IFT Form

  CHECK LIST

  • Check Fuel

  • Check WiFi

  • Log Into Laptop

  • Log Into WARDS

  • Create Patient File

  • Record Station Time

  • Prepare Paperwork

MILEAGE TRACKING:

Use the trip odometer to track mileage to the 10th of a mile.

Medicare / Medicaid requires a decimal point.

DO NOT LOG THE PRIMARY ODOMETER MILEAGE

Reset the trip odometer at the origin facility.

Start mileage should always be 0.0 in WARDS and in the narrative.

Log into WARDS and create your patient file.

Run number format:  IFT-MMDDYYYY-Last Name

Example: 

2019-07-09.png

Report Requirements

  1. Patient Name

  2. D.O.B.

  3. SS Number

  4. Billing Address

  5. Phone Number

  6. Pick up location & Address

  7. Pick up time

  8. Destination & Address 

  9. Drop off time

  10. 1 Set of vitals

  11. Total mileage

  12. Transferred care to:

  13. Who signed the HIPAA

  14. Who signed the PCS

  15. Why was ambulance necessary.

  16. Reason patient was transferred.

Paperwork Requirements

  1. Signed PCS Form

  2. Signed HIPAA

  3. Hospital FIN (Face Sheet)

  4. Insurance Info (May be on the face sheet)

  5. Completed Narrative

  6. Completed WARDS Report

  7. Scan or Store Documents

  8. IFT form submitted by crew​

Completion Requirements

  1. Fuel Unit

  2. Clean Unit

  3. Complete IFT Form

  4. Submit paperwork

SAMPLE - Narrative Template - Copy/Paste into WARDS

​

R: (Response) Great Lakes EMS Inc was requested to transport a patient to (Destination Facility). 
Unit 3Z** was dispatched to (Origin Facility) for patient pick up on (ROOM FLOOR ER)
EMS Crew:  Your Name EMT-? and Partner Name - EMT-?

 

Mileage at Origin 0.0

 

C: (Chief Complaint) - Transfer to FACILITY for THESE REASONS indicated in the PCS form. 

 

H (History) - Dispatched to a Health Facility - Hospital for a  **  year old MALE/FEMALE requiring Transfer/Interfacility/Palliative Care.

 HOSPITAL  does not have the specialists to treat this patient,  HOSPITAL agreed to accept the patient for immediate interventions. 

​

A (Assessment) - Pain, vitals, GCS, etc 

​

Rx (Rendered Treatment) -  Position of comfort, patient monitoring, ---- monitor oxygen, vitals. (etc etc etc what you did)

​

D (Destination) - The patient was transported Non-Emergent to HOSPITAL. The destination was determined by Patient's Physician's Choice, Regional Specialty Center and special services available at the destination facility. 

Patient was transferred to ROOM NUMBER/ER to NURSE/DOCTOR NAME at TIME

​

Physician Certificate signed by: Nurse / Doctor name - RN, DO, MD, Etc 

 

HIPAA signed by patient PATIENT NAME, witnessed by EMT NAME AND LICENSE LEVEL

 

Arrival at destination 00:00  

​

Mileage 000.0

Origin Hospitals

Aurora - Oshkosh                 855 N Westhaven Dr, Oshkosh, WI 54904

Aurora - Baycare                  2845 Greenbrier Rd, Green Bay, WI 54311

Mercy - Oshkosh                   500 S Oakwood Rd, Oshkosh, WI 54904

St. Elizabeth                          1506 S Oneida St, Appleton, WI 54915

ThedaCare - Neenah            130 2nd St, Neenah, WI 54956

ThedaCare - Appleton          1818 N Meade St, Appleton, WI 54911

ThedaCare - New London    1405 South Mill St, New London, WI 54961

Bellin Hospital                       744 S Webster Ave, Green Bay, WI 54301

St Vincent Hospital               835 S Van Buren St, Green Bay, WI 54301

VA Hospital - Waupaca         N2692 County Rd QQ, Waupaca, WI 54981

Destination Hospitals

Aurora - GreenBay                2845 Greenbrier Rd, Green Bay, WI 54311

Aurora St. Lukes                   2900 W Oklahoma Ave, Milwaukee, WI 53215

Aurora Psychiatric                1220 Dewey Ave, Wauwatosa, WI 53213

VA Hospital (Zablocki)           5000 W National Ave, Milwaukee, WI 53295

Froedtert Hospital                 9200 W Wisconsin Ave, Milwaukee, WI 53226

Children's Milwaukee            SAME Ambulance Bay / Entrance (8915 W Connell Ct, Milwaukee, WI 53226)

UW - Madison                        600 Highland Ave, Madison, WI 53792

Children's Madison               SAME ER Doors / Entrance (1675 Highland Ave, Madison, WI 53792)

Physician Certificate Example: 

YELLOW fields must be completed for billing.

GLEMS PCS WEB SAMPLE.jpg

HIPAA Example: 

SECTION I -    Signed by the patient.

SECTION I -    If minor child: PARENT SIGNS.

SECTION I -    EMT Should sign as a witness.

SECTION II -   Why patient is not signing.

SECTION II -   Legal guardian, spouse or POA. >18

SECTION III -  Signed by EMS and Hospital staff. 

HIPAA DEFINED CLICK HERE for details. 

HIPAA GLEMS 2019 WEB SAMPLE.jpg
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