Refusal QA Form 

Agency *
Patient Age *
Refusal Criteria
This section is to determine if the EMCT charted the following refusal criteria questions. Answers to the questions are not important, merely that they were charted.
Were the following items addressed in the chart? *
- Alert & oriented to person, place, and event - Oriented to date and time OR at their baseline mental status per witnesses on scene - Does not demonstrate or verbalize a danger to self or others - No evidence of acute neurologic insult or injury - No evidence of impairment from hemodynamic instability (hypoxia, hypotension, hypertension) - No symptomatic hypoglycemia (FSBG does not have to be taken if patient is A&Ox4) - GCS > 13 - Does not appear impaired by drugs, alcohol, or mental illness (pt can have these on board if the pass the cognitive screen)
Was a cognitive screening tool score charted? *
Was a patch made? *
This is only necessary if pt did not meet the above criteria or scored < 5/6 on the cognitive screening tool.
2 sets of vitals?
Was it charted that risks were explained to the patient?
Base Hospital review needed
No Protected Health Information