The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered.  The patient speaks coherently and exhibits no evidence of having an altered level of consciousness or alcohol or drug intoxication to a point that would impair judgment.  They respond knowingly to questions about recommended treatment and alternate treatments including no further testing or treatment;  participate in diagnostic and treatment decisions by means of rational thought processes; and understand the items of minimum basic medical treatment information with respect to that treatment (the nature and seriousness of the illness, the nature of the treatment, the probable degree and duration of any benefits and risks of any medical intervention that is being recommended, and the consequences of lack of treatment, and the nature, risks, and benefits of any reasonable alternatives).
I have reviewed the relevant issues with the patient.  They are aware of the suspected diagnosis suggested by screening exam, [***], based upon the initiated medical screening exam.  The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation.  The recommended medical care being refused has been discussed with the patient and is [***].  The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death.
The patient understands the relevant information of the nature of their medical condition, as well as the risks, benefits, and treatment alternatives (including non-treatment), consequences of refusing care, and can competently communicate a rational explanation about their choice of care options.
[Discharge instructions were provided to the patient.]   The patient understands they are welcome to return to the hospital at any time to receive the recommended care or any other care at any time, regardless of their ability to pay for such care.
Harbor Macros: AMA
SCVMC:Onboarding
Harbor Macros: Pediatrics
SCVMC:CUSTODY CARE
SCVMC:Main
RRMC:ED
OVMC:Pain and Substance Use Disorder
Maine:Prehospital protocol pediatric anaphylaxis