Refusal (Signal 8)

[comment memo="Who responded? How did you respond, immediately (unscheduled) or non-immediately (scheduled)? Where did you respond? & What did you respond for?"]
C - Dispatched[select name="variable_1" value="EC-35|EC-49|EC-50|EC-51|EC-52"] was dispatched and responded [select name="variable_2" value="immediately| non-immediately"]to the address stated    in this EPCR for [select name="variable_3" value="a emergency response | an Emergency Interfacility transfer| Non-Emergency Interfacility transfer |a Intercept | Hospital to Non-Hospital Facility Transfer|  Hospital to Hospital Transfer | Non-Hospital Facility to Hospital Transfer | Non-Hospital Facility    to    Non-Hospital Facility| a Law enforcement assist |a Standby |a Public Assistance/Other Not Listed | a urgent Interfacility Transport"]
[textarea name="variable_4" default=""]
for a dispatch complaint of [select name="variable_4" value="abdominal pain | air medical transport | an allergic reaction/sting | altered mental status | an animal bite/an assault | an Invalid assist | an automatic crash notification | back pain(non-traumatic | boating accident | breathing problems | burns/explosion | carbon monoxide/hazmat/inhalation/CBRN | cardiac arrest/death | chest pain | choking | convulsions / seizures | diabetic problem | drowning/diving/SCUBA accident | Electrocution/lighting | EMS special Service | Eye problem/injury | falls | fire | headache | healthcare    professional/admission | heart problems/ACID | hemorrhage/laceration | industrial    accident/inaccessible incident/other entrapments (non-vehicle)| medical alarm | no other appropriate    choice | overdose/poisoning/ingestion|pandemic/epidemic/outbreak | pregnancy/childbirth | psychiatric problems/abnormal behavior/suicide attempt | sick person | stab/gunshot wound/penetrating trauma | transfer/Interfacility/palliative care | traumatic injury | an unconscious/fainting | an unknown problem/person down | well person check"]

H - The PT reports complaining of [comment memo="What the PT is    complaining    of"] [textarea name="chiefcomplaint" default=""].

The PT reports pain level at [select name="variable_5" value="0|1|2|3|4|5|6|7|8|9|10"]

The PT has a medical history of [checkbox name="variable_1" value="COPD|CHF|HTN|chronic renal failure/ckd|diabetes|cardiac arrhythmias|cardiac condition|cardiac stent|dementia|parkinson’s disease|A-Fib|A-flutter|pacemaker|blood disorder|decubitus ulcers|obesity|anxiety|depression|arthritis|asthma|bi-polar|cancer|cardiac condition|cellulitis|hepitisis|gallbladder disease|gout|kidney stones|CVA/stroke|amputee|anemia|anoxic brain injury|autistic disorder|chronic pain|drug abuse|alcohol abuse|cirrhosis of liver|colostomy|contractures|crohn’s disease|DVT|diverticulitis|edema|seizures/epilepsy|gastric bypass surgery|history of falls|thyroid disease|infectious disease|neuropathy|osteoarthritis|pneumonia|substance abuse|tremors|vertigo"] [text name="otherhistorynotlisted" default=""].[comment memo="List any other medical history not listed"] 
The PT has allergies to [checkbox name="allergies" value="PCN|Sulfa|amoxicillin|aspirin|codeine|morphine|Statins|cillins|baclofen|Cipro|NKDA"] [text name="allergiesnotlisted” default=""].[comment memo="List any other allergies not listed"] 

A- Upon arrival to the PT was found [textarea name="ptlocation" default=""].
[comment memo="How the PT was found"] The PT is found to be alert and oriented X    [select name="AVPU" value="4|3|2|1"] with a GCS of [select name="GCS" value="15|14|13|12|11|10|9|8|7|6|5|4|3"]  

Assessment: 
General overall appearance:[textarea name="appearance" default=""]
Airway: [checkbox name="airway" value="open, maintained by patient, with no concern for compromise|open|maintained by patient|no concerns for compromise|not open|compromised|requires manual opening|requires airway adjunct|requires advanced airway"][text name="airway" size = 55 default=" "][comment memo="Any other conditions not listed"]
Breathing: [checkbox name="breathing" value="breathing spontaneously, non-labored, with a regular rate and adequate tidal volume.|tachypneic|deep|bradypneic|shallow|agonal|apneic "][text name="breathing" size = 55 default=" "][comment memo="Any other conditions not listed"]
Circulation: [checkbox name="circulation" value="normal and without concerns. |regular and normal pulse rate|tachycardic|bradycardic|weak pulse|massive hemorrhage|diminished perfusion|pulseless "][text name="circulation" size = 55 default=" "][comment memo="Any other conditions not listed"]
Level of consciousness: [checkbox name="loc" value="alert and oriented to person, place, time, and event|alert|oriented|disoriented|person|place|time|event|arousable by verbal stimuli|arousable by painful stimuli|unresponsive"][text name="consciousness" size = 55 default=" "][comment memo="Any other conditions not listed"]
Skin: [checkbox name="skin" value="pink, warm, and dry|pale, cool, and clammy|pink|warm|dry |pale|cool|clammy|diaphoretic|hot|flushed|cyanotic|lividity|jaundiced"][text name="skin" size = 55 default=" "][comment memo="Any other conditions not listed"]
Capillary Refill:[checkbox name="CapillaryRefill" value="normal and unremarkable|less than 2 seconds|greater  than 2 seconds|less than 3 seconds|greater than 3 seconds"][text name="extremities" size = 55 default=" "][comment memo="Any other conditions  not listed"]
additional assessment findings:[textarea name="additassess" default=" "][comment memo="Any other conditions not listed"] 
HEENT: [checkbox name="head" value="normal and unremarkable|no reported pain|pupils equally round and reactive|pupils unequal"][text name="head" size = 55 default=""]
Neck: [checkbox name="neck" value="normal and unremarkable|jvd|no jvd|tracheal deviation|no tracheal deviation|no reported pain"][text name="neck" size = 55 default=" "][comment memo="Any    other conditions not listed"]
Chest: [checkbox name="chest" value="normal and unremarkable|breath sounds clear equal bilaterally|no reported pain"][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and unremarkable|no reported pain"][text name="back" size = 55 default=" "][comment memo="Any other conditions not listed"]
Abdomen: [checkbox name="abdomen " value="soft, non-tender, unremarkable|no pain "][text name="abdomen" size = 55 default=" "][comment memo="Any other conditions not listed"]
Pelvis: [checkbox name="pelvis" value="normal and unremarkable|no reported pain "][text name="pelvis" size = 55 default=" ][comment memo="Any other conditions not listed"]
Extremities: [checkbox name="extremities" value="normal and unremarkable|equal strength x4 |unequal strength|cap refill less than 2 seconds|no reported pain "][text name="extremities" size = 55 default=" "][comment memo="Any other conditions not listed"]
additional assessment findings:[comment memo="Any other conditions not listed"] [textarea name="additassess" default=" "]

vitals were obtained and recorded as:
HR:[text name="0" default=""]BPM
RR:[text name="0" default=""]BPM
BP:[text name="0" default=""]mmHg
BGL:[text name="0" default=""]mg/dl
SPO2:[text name="0" default=""]%

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

Consult: 
[checkbox name="consultcheck" value="Performed. |Not performed, Cleared capacity assessment.|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."]

Signatures: 
[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."]


Provider:
[text name="name" default=""]
[checkbox name="care" value="Paramedic |EMT |AEMT."]
Who responded? How did you respond, immediately (unscheduled) or non-immediately (scheduled)? Where did you respond? & What did you respond for?
C - Dispatched was dispatched and responded to the address stated in this EPCR for

for a dispatch complaint of

H - The PT reports complaining of What the PT is complaining of
.

The PT reports pain level at

The PT has a medical history of .List any other medical history not listed
The PT has allergies to .List any other allergies not listed

A- Upon arrival to the PT was found
.
How the PT was found The PT is found to be alert and oriented X with a GCS of

Assessment:
General overall appearance:

Airway: Any other conditions not listed
Breathing: Any other conditions not listed
Circulation: Any other conditions not listed
Level of consciousness: Any other conditions not listed
Skin: Any other conditions not listed
Capillary Refill: Any other conditions not listed
additional assessment findings:
Any other conditions not listed
HEENT:
Neck: Any other conditions not listed
Chest:
Back: Any other conditions not listed
Abdomen: Any other conditions not listed
Pelvis: Any other conditions not listed
Extremities: Any other conditions not listed
additional assessment findings:Any other conditions not listed


vitals were obtained and recorded as:
HR:BPM
RR:BPM
BP:mmHg
BGL:mg/dl
SPO2:%

Reason for refusal:


Consult:





Signatures:




Additional Notes:



Provider:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.46, 75 form elements, 117 boilerplate words, 21 text boxes, 10 text areas, 19 checkboxes, 7 drop downs, 18 comments, 192 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: