EMS REFUSAL DOCUMENT 2023

[checkbox name="AMA" value="The patient has made the decision to refuse EMS medical care/transport."][conditional field="AMA" condition="(AMA).is('The patient has made the decision to refuse EMS medical care/transport.')"] The patient has decided to refuse care 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)/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 patient has capacity to refuse care. Physician also advises the patient should seek medical care via EMS to emergency department. This advice is explained to patient and they understand. 

[/conditional]


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 hospital 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.|Patient is explained that monitoring of condition alone without seeking further medical care is very dangerous"]. 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 the patient is in [checkbox name="condition" value="stable|unstable|critical"] condition. 


[checkbox name="family" value="Patients plan to refuse care 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 and have also stated their concern to the patient of risk to the patients health."] 

Refusal document is fully explained to patient, patient understands document and signs.