LCEMS REFUSAL 2024

D - (DISPATCH INFORMATION)
On [date name="variable_1" default="05-07-2024"]  Dispatched Priority __ to residence for:[textarea name="variable_1" default=""]
 
C - (CHIEF COMPLAINT)
[text name="variable_2" default="   "] year old [checkbox name="variable_3" value="Male|Female"]COMPLAINING OF:[textarea name="variable_4" default=""]
 
H - (HISTORY OF PRESENT ILLNESS)
SEE ABOVE FOR MEDICAL HISTORY/CURRENT MEDICATIONS/ALLERGIES
 
LAST ORAL INTAKE:[textarea name="variable_5" default=""]
 
EVENTS LEADING UP TO THE CALL:[textarea name="variable_6" default=""]
 
Additional information:[textarea name="variable_15" default="    "]

A - (ASSESSMENT FINDINGS)
ON SCENE PRIOR TO EMS ARRIVAL:[textarea name="variable_7" default=""] 
 
TREATMENTS PRIOR TO EMS:[textarea name="variable_8" default=""]
 
ONSET (WHEN DID THIS START):[textarea name="variable_9" default=""]
 
PROVOCATION (WHAT MAKES IT BETTER OR WORSE):[textarea name="variable_10" default=""]
 
QUALITY (DESCRIBE IT, CONSISTENT/CHANGES):[textarea name="variable_11" default=""]
 
REGION/RADIATION (AFFECTED AREA, PREVIOUS ISSUES):[textarea name="variable_12" default=""]
 
SEVERITY (PAIN SCALE, ACUTE OR CHRONIC PROBLEM):[textarea name="variable_13" default=""]
 
TIME (HOW HAS IT PROGRESSED):[textarea name="variable_14" default=""]
 
ADDITIONAL ASSESSMENT FINDINGS:

Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Speech is not slurred; CMS grossly intact in all 4 extremities; gait is steady. "]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. Pulse strong and regular. "]
PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. Normal and adequate tidal volume and respiratory drive. Lung sounds clear and equal. "]
GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported. "]

Physical Exam:
HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. Patient denies Headache, or dizziness. "]
EYES:[textarea name="variable_1" default=" PERRL. No blurred vision is expressed."]
NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "]
THROAT: [textarea name="variable_1" default="Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. "]
CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm. "]
ABDOMEN: [textarea name="abd" default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses. "]
PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]

TREATMENT: 
[textarea name="treatment" default=" "]

EMS CREW OFFERED TRANSPORT TO A HOSPITAL (x) YES ( ) NO

(x) PT DOES NOT WISH TO BE TRANSPORTED TO THE HOSPITAL: [Not Entered]
(x) PT IS AT THEIR NORMAL LOC AND IS ABLE TO AMBULATE/AT BASELINE MOBILITY
(x) PT DOES NOT APPEAR TO BE UNDER THE INFLUENCE OF ALCOHOL, DRUGS, OR OTHER MIND ALTERING SUBSTANCES OR CIRCUMSTANCES THAT MAY INTERFERE WITH MENTAL FUNCTIONS
(x) PT IS NOT A CLEAR DANGER TO SELF OR OTHERS
(x) PT IS 18 YEARS OF AGE OR OLDER
(x) PT WAS CLEARLY INFORMED OF THE NATURE OR ILLNESS/INJURY AND THE NEED FOR EMERGENCY CARE/TRANSPORT
(x) PT IS AWAKE, ORIENTED, CAPABLE AND COMPETENT OF UNDERSTANDING THE CIRCUMSTANCES OF REFUSING TREATMENT AND TRANSPORT
(x) PT ADVISED TO CALL 911 IF ANY CHANGES OR CONCERNS
MEDICAL CONTROL CONTACTED: ( ) YES ( ) NO
PHYSICIAN:

[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. 
D - (DISPATCH INFORMATION)
On Dispatched Priority __ to residence for:


C - (CHIEF COMPLAINT)
year old COMPLAINING OF:


H - (HISTORY OF PRESENT ILLNESS)
SEE ABOVE FOR MEDICAL HISTORY/CURRENT MEDICATIONS/ALLERGIES

LAST ORAL INTAKE:


EVENTS LEADING UP TO THE CALL:


Additional information:


A - (ASSESSMENT FINDINGS)
ON SCENE PRIOR TO EMS ARRIVAL:


TREATMENTS PRIOR TO EMS:


ONSET (WHEN DID THIS START):


PROVOCATION (WHAT MAKES IT BETTER OR WORSE):


QUALITY (DESCRIBE IT, CONSISTENT/CHANGES):


REGION/RADIATION (AFFECTED AREA, PREVIOUS ISSUES):


SEVERITY (PAIN SCALE, ACUTE OR CHRONIC PROBLEM):


TIME (HOW HAS IT PROGRESSED):


ADDITIONAL ASSESSMENT FINDINGS:

Assessment:
GENERAL:

CNS:

PSYCH:

CARDIOVASCULAR:

PULMONARY:

GI/GU:


Physical Exam:
HEAD:

EYES:

NECK:

THROAT:

CHEST:

BACK:

ABDOMEN:

PELVIS:

EXTREMITIES:

SKIN:

VITALS:

EKG:


TREATMENT:


EMS CREW OFFERED TRANSPORT TO A HOSPITAL (x) YES ( ) NO

(x) PT DOES NOT WISH TO BE TRANSPORTED TO THE HOSPITAL: [Not Entered]
(x) PT IS AT THEIR NORMAL LOC AND IS ABLE TO AMBULATE/AT BASELINE MOBILITY
(x) PT DOES NOT APPEAR TO BE UNDER THE INFLUENCE OF ALCOHOL, DRUGS, OR OTHER MIND ALTERING SUBSTANCES OR CIRCUMSTANCES THAT MAY INTERFERE WITH MENTAL FUNCTIONS
(x) PT IS NOT A CLEAR DANGER TO SELF OR OTHERS
(x) PT IS 18 YEARS OF AGE OR OLDER
(x) PT WAS CLEARLY INFORMED OF THE NATURE OR ILLNESS/INJURY AND THE NEED FOR EMERGENCY CARE/TRANSPORT
(x) PT IS AWAKE, ORIENTED, CAPABLE AND COMPETENT OF UNDERSTANDING THE CIRCUMSTANCES OF REFUSING TREATMENT AND TRANSPORT
(x) PT ADVISED TO CALL 911 IF ANY CHANGES OR CONCERNS
MEDICAL CONTROL CONTACTED: ( ) YES ( ) NO
PHYSICIAN:

The patient has decided to refuse care because they do not believe their condition warrants further care/transport by EMS.

The risks of refusal have been explained to the patient, including , 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 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 hospital workup under the care of a physician. Follow-up has been emphasized and patient plans on . 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 condition.




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

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.2, 46 form elements, 369 boilerplate words, 3 text boxes, 32 text areas, 1 dates, 8 checkboxes, 2 conditionals, 56 total clicks
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