EMS PEDS REFUSAL DOCUMENT

[checkbox name="AMA" value="The patients parent(s)/guardian have made the decision to refuse EMS medical care/transport."][conditional field="AMA" condition="(AMA).is('The patients parent(s)/guardian have made the decision to refuse EMS medical care/transport.')"] Parent(s)/guardian have decided to refuse care because they do not believe condition warrants further care/transport by EMS. [checkbox name="capacity" value="Parent(s)/guardian have rational thought process, are without clinical substance impairments, evidenced by their orientation to person, place, time, event, and the ability to do simple arithmetic. Parent(s)/guardian have no observed psychosis, delirium, dementia, or disorientation. Parent(s)/guardian have intact decision making capacity."] 

The risks of refusal have been explained to the parent(s)/guardian, including [text default="" size="60"], worsening of condition, incapacitation, subsequent illness or injury, or worst-case scenario, death. The benefits of care by EMS and transport to ED have also been explained, including the availability and proximity of emergency equipment, monitoring, EMS provider treatment, and at the ED- nurses, physicians, monitoring, diagnostic testing, and definitive treatment. Parent(s)/guardian able to understand and state the risks and benefits of care refusal vs. care by EMS. This was witnessed by [checkbox name="witness" value="other EMS providers present at scene| and patients family member(s)/support people | and other bystanders present at scene | and police officers present"] and myself.


[checkbox name="callin" value="Refusal is against medical advice."][conditional field="callin" condition="(callin).is('Refusal is against medical advice.')"] Denver Health is contacted and Dr. [text name="doc" default=""] is consulted. They are fully explained clinical scenario including aforementioned H&P findings. Physician shares concern but agrees parent(s)/guardian have capacity to refuse care for child. Physician also advises the patient should seek medical care via EMS to emergency department. This advice is explained to parent(s)/guardian and they understand. 

[/conditional]


Parent(s)/guardian had the opportunity to have questions answered about childs medical condition and care needed. The patient was treated to the extent that they would allow and parent(s)/guardian know that they may call 911 back or go to the ED for care at any time. Parent(s)/guardian clearly understands that evaluation by EMS is not equivalent to a complete hospital workup under the care of a physician. Follow-up has been emphasized and they   plan on [checkbox name="plan" value="contacting primary caregiver ASAP|POV transport to ED|POV trasnport to Urgent Care|monitoring for worsening of condition without seeking further medical care.|Parent(s)/guardian is explained that monitoring of condition alone without seeking further medical care is very dangerous"]. It has been stressed to the parent(s)/guardian that they may go to the ED or call 911 back with any additional concerns. At the time of refusing the patient is in [checkbox name="condition" value="stable|unstable|critical"] condition. 


[checkbox name="family" value="Plan to refuse care has been also been discussed with|family/support people who agrees with the parent(s)/guardian wish to refuse care and verbalizes their understanding of risk to patients health.|family/support people who disagree with plan to refuse and have also stated their concern to the patient of risk to the patients health."] 

Refusal document is fully explained to parent(s)/guardian, parent(s)/guardian understands document and signs. 

Parent(s)/guardian have decided to refuse care because they do not believe condition warrants further care/transport by EMS.

The risks of refusal have been explained to the parent(s)/guardian, including , worsening of condition, incapacitation, subsequent illness or injury, or worst-case scenario, death. The benefits of care by EMS and transport to ED have also been explained, including the availability and proximity of emergency equipment, monitoring, EMS provider treatment, and at the ED- nurses, physicians, monitoring, diagnostic testing, and definitive treatment. Parent(s)/guardian able to understand and state the risks and benefits of care refusal vs. care by EMS. This was witnessed by and myself.





Parent(s)/guardian had the opportunity to have questions answered about childs medical condition and care needed. The patient was treated to the extent that they would allow and parent(s)/guardian know that they may call 911 back or go to the ED for care at any time. Parent(s)/guardian clearly understands that evaluation by EMS is not equivalent to a complete hospital workup under the care of a physician. Follow-up has been emphasized and they plan on . It has been stressed to the parent(s)/guardian that they may go to the ED or call 911 back with any additional concerns. At the time of refusing the patient is in condition.




Refusal document is fully explained to parent(s)/guardian, parent(s)/guardian understands document and signs.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.78, 11 form elements, 128 boilerplate words, 2 text boxes, 7 checkboxes, 2 conditionals, 20 total clicks
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