Dispatch

ProMed Ambulance Company Unit Unit Number was dispatched to Pick-Up Location or Address for a patient complaining of Dispatch Complaint.
Unit responded emergent with: Crew Members.

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Complaint

Unit arrived on scene to find a Age-year-old Gender patient REPLACE ME (position patient found).
Patient is alert and oriented to REPLACE ME (A&Ox level).
Patient reports Chief Complaint, which began at REPLACE ME (onset time).

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History

Past Medical History: REPLACE ME.
Allergies: REPLACE ME or NKDA.
Patient additionally reports REPLACE ME (symptom history, prior similar episodes, home medications if relevant).

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Assessment

REPLACE ME (overall assessment: general appearance, airway, breathing, circulation, mental status).
Vital signs obtained and documented.
No life-threatening abnormalities noted OR list abnormalities here if present.

If patient refuses parts of the exam:

Patient refused REPLACE ME (e.g., vitals, glucose check, EKG, full assessment) despite explanation of need.

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Rx / Treatments

No interventions performed.
Vital Signs obtained and documented.
If patient refused offered treatments (oxygen, bleeding control, EKG, etc.):

Patient declined REPLACE ME after risks explained.

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Transport (Refusal Documentation)

The patient is refusing transport after EMS evaluation.

Capacity Check (Required Documentation)

Patient demonstrated decision-making capacity by:

• Understanding their condition and the risks of refusing transport

• Repeating back the risks in their own words

• Making a consistent, voluntary decision

• Showing no signs of impaired judgment due to drugs/alcohol/mental status

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Risk / Consequence Explanation

The following risks were explained to the patient:
REPLACE ME (worsening symptoms, permanent disability, infection, stroke, heart attack, or death depending on call).
Patient verbalized understanding of these risks and stated REPLACE ME (their reason for refusing).

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Signature & Disposition

Patient refusal signature obtained OR signature witnessed by REPLACE ME if patient unable/unwilling to sign.
Patient left in the care of Self / Family / Law Enforcement / Caregiver.
Patient was advised to call 911 again if symptoms persist, worsen, or new symptoms develop.

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Exceptions

REPLACE ME
(Delays, scene hazards, patient behavior, partial refusals, LE involvement, time constraints, etc.)

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END