Call / Arrival DO NOT enter patient name, DOB, address, phone number, MRN, insurance information, or other patient-identifying information into DocGen.
Provider level
Select… EMR
Scene safety
Select… Scene safe Scene made safe Hazard present / mitigated Unable to fully assess
PPE / standard precautions
Select… Appropriate PPE used Additional PPE used No special PPE required Other
Dispatch / response reason
Patient position / location on arrival
General impression
Select… No apparent immediate distress Mild distress Moderate distress Severe distress Critical / peri-arrest Cardiac arrest
Responsiveness
Select… Alert Responds to verbal stimulus Responds to painful stimulus Unresponsive
Orientation
Select… A&O x4 A&O x3 A&O x2 A&O x1 Not oriented Unable to assess
Initial scene / presentation notes
Primary Assessment Airway
Select… Patent Patent with secretions Partially obstructed Completely obstructed Maintained with positioning Maintained with adjunct Unable to assess
Breathing effort
Select… Normal / unlabored Mildly increased Moderately labored Severely labored Agonal Apneic Unable to assess
Respiratory pattern
Select… Regular Irregular Tachypneic Bradypneic Shallow Deep Kussmaul-type Cheyne-Stokes-type Other / unable to assess
Circulation / perfusion
Select… Adequate Concern for poor perfusion Shock suspected Cardiac arrest Unable to assess
Radial pulse
Select… Strong Weak / thready Irregular Absent Not assessed
Major hemorrhage
Select… None identified Controlled before arrival Controlled by first responders Ongoing / difficult to control Unable to assess
Primary assessment notes
History Chief complaint
Onset
Provocation / palliation
Quality
Region / radiation
Severity
Time / duration / progression
History details
Vital Signs / Monitoring Heart rate
Respiratory rate
Blood pressure
SpO₂
Temperature
Pain score / pain assessment
Blood glucose (if obtained / authorized)
Repeat vital signs / trend
Focused / Physical Assessment Head / face
Select… No abnormality identified Pain / tenderness Trauma / wound Swelling Bleeding Other abnormality Not assessed
Neck
Select… No abnormality identified Pain / tenderness JVD Tracheal deviation concern Swelling Other abnormality Not assessed
Chest
Select… No abnormality identified Pain / tenderness Trauma Unequal rise Crepitus Other abnormality Not assessed
Abdomen
Select… Soft / non-tender Tender Guarding Rigid Distended Mass / pulsation concern Other abnormality Not assessed
Pelvis
Select… No abnormality identified Pain / tenderness Instability concern Other abnormality Not assessed
Back / spine
Select… No abnormality identified Pain / tenderness Deformity / step-off concern Other abnormality Not assessed
Upper extremities
Select… No abnormality identified Pain / tenderness Deformity Swelling Wound Neurovascular deficit concern Other abnormality Not assessed
Lower extremities
Select… No abnormality identified Pain / tenderness Deformity Swelling Wound Edema Neurovascular deficit concern Other abnormality Not assessed
Additional exam findings
Treatments / Interventions Treatment details
Response to care
Select… Improved Unchanged Worsened Mixed response Not reassessed / care immediately transferred Unable to assess
Reassessment findings
Disposition First-response encounter outcomeEMR personnel should not use this selection as a patient refusal form. When a patient declines care or interaction, request / notify an appropriate higher-level EMS resource and document the circumstances according to current Vermont requirements and agency policy.
Select… Care transferred to higher-level EMS / transporting service No patient located / no patient contact Call cancelled / cleared before patient contact Patient declined first-response interaction or care; higher-level EMS requested / notified
Transfer of Care - Complete when care is transferred Transporting EMS service / agency
Transporting unit
Level of provider assuming care
Select… EMR EMT AEMT Paramedic RN Other Unknown
Patient condition at transfer
Select… Improved Unchanged Worsened Critical Other
Approximate transfer-of-care time
First-response crew assisted after transfer
Select… No Yes - assisted transport crew before departure Yes - accompanied transport crew Not applicable
Transfer-of-care notes
EMR personnel do not complete the refusal workflow contained in the EMT/AEMT templates. If a patient declines assessment, treatment, or continued interaction before transfer of care, request / notify higher-level EMS as appropriate and document objective observations and actions taken.
Did the patient decline first-response interaction or care?
Select… No / not applicable Declined assessment Declined treatment Declined continued interaction Left / departed before higher-level EMS assumed care Other
Higher-level / transporting EMS requested or notified
Select… Yes No - not applicable Unable to contact / request Already responding / already present
Observed patient status when interaction / care was declined
Select… Alert and communicating Altered / concerning mental status Medical distress present No obvious immediate distress Unable to adequately assess Other
Objective documentation of decline / handoff circumstances
Discussion
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