4. All necessary equipment, medications, and machine shall be provided by the hospital during conduction.

All medications
and CSR supply which will be used during the conduction shall be charged and should be paid on a cash basis by the patient
transferred to other hospital or shall be included in the final bill of admitted patient.
5. In instances that the hospital ambulance is not available and/or necessary machine/s needed during conduction is not
accessible, the patient and/or relative may choose for a reliable outsource ambulance listed at the Information Section. The
fee for the outsource ambulance depends on the agency’s policy. (See policy on Outsource Ambulance Conduction)
6. In instances that the patient/relative decidedto provide an ambulance on their own without a doctor and a nurse, the
FAMED/ROD shall explain the significances and a DAMA/HAMA form shall be signed by the relative.
Shared Staffing
Supervisor’s Responsibilities:
1. The ER Head Nurse or charge nurse shall assign an ER nurse who will accompany the patient during ambulance
conduction. However, the Nurse Supervisor shall assign the most flexible staff from other unit in cases that the ER Nurses
cannot accommodate the conduction due to increase patient demand in the Emergency Room.
2. The nurse supervisor is responsible for arranging schedule of patients for hospital ambulance conduction to prevent
overlapping.
3. The nurse supervisor on duty is responsible for informing the ER Resident on Duty and the ambulance driver regarding
the ambulance conduction including the time, date and location.
4. One (1) hour prior to the departure time the Supervisor on duty shall remind the ER Nurse who will accompany the
patient,to prepare the ambulance kit and other materials needed during the ambulance conduction that the patient may need.
Ambulance kit inventory shall be done together with the pharmacy personnel.
1. Attending Physician will order the diagnostic procedure to be done to the patient including the hospital and exact time the
procedure will be done.
2. The NOD shall inform the FAMED/ROD/JC regarding the Attending Physician’s order.
3The NOD shall obtain consent from the patient or authorized relative by signing the special procedure consent.

5.0 procedure
1. The hospital ambulance is under the GSD who shall coordinate all activities and whereabouts to the NSO for proper
scheduling of conduction/s.
2. The hospital ambulance shall only accommodate patients who will;
 Undergo a certain procedure to other hospital.
 Advised to be transferred or opted to be transferred to other hospital.
As soon as the NOD determines that the patient has a desire or will be advised by the AP for THOC or undergo certain
procedure to other hospital the supervisor must be informed beforehand to consider possible used of the hospital ambulance.
3. It is a policy of the hospital that an emergency nurse, a doctor, and one relative shall accompany the patient during
ambulance conduction. A fee for ambulance shall be charged to the patient and should be settled prior to the conduction
except for HMO patients with LOA.Confirmation of HMO approval must be done prior to scheduling. The fee is non-
refundable once patient has been transported whether the procedure has been done or not due to any circumstances.

5.2 Round Trip Ambulance Conduction

7. All documents and or files necessary for conduction shall be accomplished by the personnel involved such as;
 THOC consent (See THOC policy)
 Special Procedure Consent
  Diagnostic and or Laboratory results
 HMO LOA- if ambulance conduction and or procedure are covered
8. In cases wherein the patient is for ICU and there is no available bed in the unit, it is the AP’s prerogative if patient will be
transferred to another hospital. The AP shall be the one to advise the patient/relative that patient needs to be transferred and
will then order to the Doctor’s Order Sheet that patient is for transfer.
9. Any consent shall only be explained by a physician, and signature shall be obtained by the NOD and another witness.
Consent should be signed by any of the following:
 Legal Spouse
 Eldest child of legal age (in the absence of spouse for married patients)
 Parent/ Legal Guardian (for patient <18 y/o)
 In the absence of a legal next of kin to decide, the Attending Physician, or the Hospital Administrator/s could make
a decision on behalf of the patient.
 Name of the Patient
 Room
 Age
 Gender
 Diagnosis

5.1 THOC
 Contraptions
 Date and time of transfer
 Hospital of Choice
 Reason for Transfer
Meadville Medical Center
St. Vincent's
Titusville
LF north
Nurse’s Responsibilities
1. The nurse must monitor the patient during the travel and ensure patient’s safety inside the ambulance.
2. The nurse is responsible on all the pharmacy and CSR supplies during the ambulance conduction and shall ensure all
content of the ambulance kit and other medical equipment are complete upon return to the pharmacy and CSR. Used
medical supplies must replenish right away and charged right away. (Forward AR and payment to the cashier/forward
charge slip to the pharmacy and or CSR).
3. The NOD who will go along with the conduction will be responsible in returning any unused AR to the Cashier.
4.The nurse must ensure that the patient’s chart, diagnostic results, hospital linens and other hospital belongings will be
brought upon return to the hospital and be endorsed and returned to its proper custodians.
5. Upon the return to the hospital the nurse has to document all pertinent data on the nurse’s note and endorse to the NOD.
5.Once coordinated the NOD shall inform the supervisor on duty that patient is for round trip ambulance conduction. The
supervisor must be informed of the following information;
  Name of the patient
 Room
 Age
 Gender
 Diagnosis
 Contraptions
 Procedure to be done
 Schedule of the Procedure (Time and Date)
 Hospital where the procedure will be done
10. Thirty (30) minutes prior to the departure time the Nurse who will accompany the patient shall fetch the patient in the
unit for proper endorsement.
11. The NOD should close his/her nurse’s note and the patient’s chart will be endorsed to the ER Nurse.
12.Medications, contraptions, precautions and diagnostic results must also be endorsed.

definition of terms
2.0 OBJECTIVE
CHMC
Mary Kathleen D. Castillo, RN
4.0 policy
6. The NOD shall also inform/re-iterate to the patient and or relative about the price of the procedure, preparation, time and
day, and all information they have to know.
7. The NOD shall charge the ambulance prior to the conduction for settlement or inclusion to the patient’s final bill. Proper
endorsement to the next shift shall be done, if needed.
8. One (1) hour prior to departure time the NOD shall prepare the patient and will remind the ER Nurse and Supervisor on
duty regarding the ambulance conduction (if needed).
9. Arrival of the patient to the hospital/facility where procedure will be done should be 10-15 minutes before the scheduled
time. Therefore, departure time depends on the location of the hospital/facility.
2. The NOD shall notify the FAMMED/ROD/JC who shall inform the AP, if needed, coordinate to the hospital of choice
and to accomplish the following documents.
 THOC referral form or Clinical
Abstract (in duplicate copy)
 Consent for THOC
 THOC order written at the Doctor’s
Order Sheet
3. Once order for THOC has been made by the AP, the NOD shall secure a THOC consent which will be explained by the
FAMED/ROD/JC and be signed by the patient or authorized representative as a confirmation that they have fully understand
the consequences of their decision.
This policy aims to provide twenty-four (24) hour ambulance services to all patients of Commonwealth Hospital and
Medical Center requiring to be transferred and/or need to undergo certain procedures to other hospital or facility.
Nursing Service Department
General Service Department
Emergency Room
Attending Physician
Junior Consultant
Family Medicine
Cashier
Information Section
Central Supply Room
Pharmacy
XOXOXOXOXOXOXOXOXOXOXOXOXOOXOXOXO
5. The NOD will then forward the patient’s chart to the billing section together with the ambulance conduction fee charge
slip. (Return of unused patient’s supplies must be done first)
6. Once patient’s hospital bill is settled, the NOD shall inform the supervisor on duty that patient is ready for transfer.
7. The ambulance driver/orderly and ER nurse will bring the ambulance stretcher to the unit to fetch the patient. Proper
endorsement of NOD to the nurse who will accompany the patient must be done.
4. The NOD shall coordinate to the hospital where the procedure will be done. The following information must be obtained
upon coordination;
 Price of the procedure
 Preparation
 Time and Day
 Required Diagnostic / laboratory result
In cases wherein the Attending Physician coordinated the procedure in the other hospital or facility, the NOD must confirm
the schedule of the said procedure.
4. Once coordinated, the FAMED/ROD/JC shall accomplish a THOC form or Clinical Abstract in duplicate copy (original
copy will be attached to the patients chart) and a copy of all diagnostic and laboratory results shall be given to the
patient/relative by the NOD. The NOD shall reiterate to the patient/relative that only one authorized person of legal age is
allowed to accompany the patient during the conduction so as to prevent overcrowding of the vehicle that may result to
harm or delayed intervention to the patient. Clinical Abstract should be duly charged by the NOD.

policy on ambulance conduction

1. If the patient/relative is advised by the AP and or opted to be transferred via hospital ambulance, the NOD shall notify the
supervisor on duty to ensure availability of the ambulance and shall inform the following information:
NSO - Nursing Service Office
GSD - General Service Department
HMO - Health Maintenance Organization
LOA - Letter of Approval
THOC - Transfer to Hospital of Choice
AP - Attending Physician
NOD - Nurse on Duty
JC - Junior Consultant
FAMED - Family Medicine
ROD - Resident on Duty
CSR - Central Supply Room
OR - Official Receipt
Round Trip Ambulance Conduction - ambulance conduction wherein patient will be returning to the hospital after a special
procedure/s has been done from the other hospital or facility.

1.0 SCOPE
5.0 guidelines
5. For THOC, the supervisor must ensure to remind the nurse who will accompany the patient to obtain an
Acknowledgement Receipt (AR) from the Cashier Section. For round-trip ambulance conduction the nurse may charge the
used medical and CSR supply upon return to CHMC.
6. Thirty (30) minutes prior to the departure time the supervisor must ensure that the nurse who will accompany the patient
is already in the unit for proper endorsement.
7. The supervisor shall accomplish an ambulance trip ticket. To accomplish in duplicate copy and shall be given to the
ambulance driver and security guard.
8. The security guard will indicate time of departure and time of arrival on the trip tickets. The copy of the security guard
will be returned to the supervisor upon arrival for filing purposes and the other copy will be kept by the ambulance driver.