EMS REFUSAL DOCUMENT 2022
[checkbox name="AMA" value="The patient has made the decision to refuse EMS medical care/transport against medical advice."][conditional field="AMA" condition="(AMA).is('The patient has made the decision to refuse EMS medical care/transport against medical advice.')"] The patient has decided to refuse care against medical advice because they do not believe their condition warrants further care/transport by EMS. [checkbox name="capacity" value="The patient has rational thought process, is without clinical substance impairments, evidenced by their orientation to person, place, time, event, and the ability to do simple arithmetic. Patient has no observed psychosis, delirium, dementia, or disorientation. The patient has intact decision making capacity."] The risks of refusal have been explained to the patient, including [text default="" size="60"], worsening of their 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. The patient was 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)/suppport people | and other bystanders present at scene | and police officers present"] and myself. The patient had the opportunity to have questions answered about their medical condition and care needed. The patient was treated to the extent that they would allow and knows that they may call 911 back or go to the ED for care at any time. The patient clearly understands that evaluation by EMS is not equivalent to a complete hopsital workup under the care of a physician. Follow-up has been emphasized and patient plans 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- although this is explained to be dangerous and that medical care is needed"] [text default="" size="60"]. It has been stressed to the patient that they may go to the ED or call 911 back with any additional concerns. At the time of refusing AMA the patient is in [checkbox name="condition" value="stable|unstable|critical"] condition. [checkbox name="family" value="Patients plan to refuse care AMA has been also been discussed with|family/support people who agrees with the patients wish to refuse care and verbalizes their understanding of risk to patients health.|family/support people who disagree with patients plan to refuse AMA and have also stated their concern to the patient of risk to the patients health."] AMA document is fully explained to patient, patient understands document and signs. [/conditional]
There are 9 form elements.