New Refusal

Incident:[textarea name="incident" default=" EMSA  was dispatched Priority  to "]

Upon Arrival: [textarea name="ptinfo" default=" On arrival EMS "]

Complaints: [textarea name="Chiefcomplaint" default=" "]

Hx (If given): [textarea name="hx" default=" "]

Focused Assessment: [textarea name="assessment" default=" "]

Interventions: [textarea name="interventions" default=" "]

Reason for refusal: [textarea name="refusal" default=" "]

[checkbox name="consultcheck" value="Performed. |Not performed, Cleared capacity assessment. |FOS |OMD |OLMC |Aftercare instructions left."] 
[textarea name="consulttext" default=" "]

[checkbox name="refusal" value="Despite multiple attempts by myself and my partner to convince the patient (and/or responsible party) to be transported to the hospital for further evaluation and treatment, the patient remains adamant that they do not want to go. The patient/guardian is oriented, clear of mind, and has the capacity to understand the presented information. This patient/guardian has verbalized full understanding of their symptoms and understand that forgoing further evaluation and/or treatment could pose a significant medical risk to the patient's life. The patient/guardian has verbalized that they understand our treatment plan, including interventions and transport destination, and does not want these interventions at this time. Furthermore, the patient/guardian acknowledges that forgoing this treatment could lead to worsening of condition up to and including death. The patient/guardian understands that they are free to call 911 should the patient's condition worsen, or they later decide that they wish to be transported to the Emergency Department for further evaluation and intervention. EMS also ensured that the patient/guardian was aware of other resources available such as contacting their Primary Care Provider or visiting Urgent Care or Emergency Department on their own. The patient/guardian acknowledged these resources."]

[checkbox name="signatures" value="Patient signed refusal. |Parent/guardian signed refusal| Patient refused to sign. |Refusal signature witnessed by"] 
[textarea name="refusalsignature" default=" "]

Additional Notes: 
[textarea name="variable_1" default=" No additional."]

[text name="prov" size = 45 default=" "]
[checkbox name="care" value="NRP. |EMT. |AEMT. |EMT-I"]

Upon Arrival:


Hx (If given):

Focused Assessment:


Reason for refusal:



Additional Notes:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.27, 15 form elements, 18 boilerplate words, 1 text boxes, 10 text areas, 4 checkboxes, 26 total clicks
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