RAHC EMS Refusal

DISPATCH:
On [date name="date"] Fort Sill EMS unit [select value="161|171|172"] was called [select value="emergency status|non-emergency status"] to [select value="above location|TMC|UCC"] for [text] y/o [select value="male|female"] with complaints of [text] per dispatch. FSFD [select value="was|was not"] dispatched on this call.
ARRIVAL:
Upon arrival [textarea]
CHIEF COMPLAINT:
[select value="PT|Caregiver|Bystander|Provider|FSPD|FSFD"] states [textarea].

HISTORY:
PMH: [textarea]
HPI: [textarea]
Allergies: [textarea]
Medications: [textarea]

ASSESSMENT:
Primary:

Mentality
[checkbox value="AAOx4|GCS 15|Altered|Confused|Responsive to verbal|Responsive to pain|Unresponsive"]
[text]

Airway
[checkbox value="Patent airway|Partially obstructed airway|Occluded airway"]
[text]

Breathing:
[checkbox value="Adequate breathing|Inadequate breathing|Absent breathing"]
[text]

Circulation
[checkbox value="Adequate circulatory status|Compromised circulatory status|Inadequate circulatory status "]
[text]
Detailed:
HEENT:
[checkbox value="No bleeding or trauma noted, PERRL, open airway, appropriate and adequate breathing, no JVD noted, no tracheal deviation, no significant findings"]
[text]

Chest:
[checkbox value="No bleeding or trauma noted, LSCTAx4, equal and bilateral breath sounds, no significant findings"]
[text]

Abdomen:
[checkbox value="No bleeding or trauma noted, non-tender X 4 quads, no distention noted, bowel sounds present, no significant findings"]
[text]

Pelvic:
[checkbox value="No bleeding or trauma noted, no significant findings"]
[text]

Upper extremities:
[checkbox value="No bleeding or trauma noted, CMS equal and present, no significant findings"]
[text]

Lower extremities:
[checkbox value="No bleeding or trauma noted, CMS equal and present, no significant findings"]
[text]

Back:
[checkbox value="No bleeding or trauma noted, LSCTAx4, equal and bilateral breath sounds, no significant findings"]
[text]

Initial Vitals:
Blood pressure [text]/[text]. Pulse [text]. Resp rate [text] O2sat [text] FSBS [text] EKG [text].

TREATMENTS:
[checkbox value="None|Adult assessment|Pediatric assessment|IV established|IV fluids given|12-lead EKG|Medication(s) given|Bleeding control|Splinting"]
[text]

Explanation and Response to treatment(s):
[textarea]

[select value="Pt|Pts parent|Pt caregiver"] advised of risk, up to and including death with instructions to call 911 again if needed. Pt ecknowlaged and signed refusal. 

Ryan J Dial

________________________
NREMT-P
DISPATCH:
On Fort Sill EMS unit was called to for y/o with complaints of per dispatch. FSFD dispatched on this call.
ARRIVAL:
Upon arrival
CHIEF COMPLAINT:
states .

HISTORY:
PMH:
HPI:
Allergies:
Medications:

ASSESSMENT:
Primary:

Mentality



Airway



Breathing:



Circulation


Detailed:
HEENT:



Chest:



Abdomen:



Pelvic:



Upper extremities:



Lower extremities:



Back:



Initial Vitals:
Blood pressure /. Pulse . Resp rate O2sat FSBS EKG .

TREATMENTS:



Explanation and Response to treatment(s):


advised of risk, up to and including death with instructions to call 911 again if needed. Pt ecknowlaged and signed refusal.

Ryan J Dial

________________________
NREMT-P

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.42, 48 form elements, 91 boilerplate words, 21 text boxes, 7 text areas, 1 dates, 12 checkboxes, 7 drop downs, 68 total clicks
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