EMS Patient Care Report - 11/18/95

Date:November 18, 1995
Pages:5

PINELLAS C0UNTY EMS PATIENT CARE REPORT

Date: 11/18/95

Incident: 206964

Call Received: 1755

Patient: 01 of 01

Dispatch: 1755

Pat Depart: 1830

En Route: 1755

Unit Depart: 1830

Arrive Loc: 1755

Arrive Dest: 1838

Pat Contact: 1756

Available: 1901

Nature of Call: Behavioral

Call Status: _X_ To Scene _X_ From Scene

Call Level: ALS

Exposure: No

Assist: EMS

Disposition: Transport

Type of Transport: Ground

Incident Location: 515 Belleview Bl

Last Name: McPherson

First Name: Lisa

Street Address: 2324 Jonesboro Av

City: Dallas

State: TX

Zip: 75228

Date of Birth: 2/10/59

Sex: Female

Race: White

Age: 36

Airway: Patent

Breathing: Sounds

Temp: WNL

Color: WNL

Moisture: WNL

Pupils: _X_ WNL _X_ WNL

Glasgow Coma Scale:

Eyes: Spont

Verbal: Confused

Motor: Obeys

Total: 14

Circulation: Radial

Time: 1812

Pulse: 126

Resp Rate: 18

BP Systolic: 160

BP Diastolic: 102

PINELLAS COUNTY EMS SUPPLEMENTAL SHEET

Patient Name, Last, First: McPherson, Lisa

Skin w/n, * PMS y4, ABP S & NT, Pt stated she's having a difficult time & / t doing bad things in her mind & doing wrong things that she didn't know were wrong. One example "I took my eyes off the object" VP, 10, 20, EKG, GSC trans ALS -> MPH s incident pt states she needs to rest.

REFUSAL OF CARE ALGORITHM

[This is the back of the EMS Patient Care Report. It includes an ECG Strip marked:]

18:13 18 NOV 95 LEAD II XI 0_HR=127

RELEASE OF MEDICAL ASSISTANCE

A Release of Medical Assistance form, signed by Lisa McPherson.

It says:

I (or my guardian) have been informed of the reason I should go to a hospital for further emergency care.

I (or my guardian) have been informed of the evaluation and/or treatment that will/may occur when I get to the hospital.

I (or my guardian) have been informed of the potential consequences and/or complications that may result in my (or my guardian's) refusal to go to a hospital for further emergency care.

As a competent adult, I (or my guardian) fully understand all of the above, and am/is capable of determining a rational decision on my behalf.

I (or my guardian), the undersigned, have been advised that emergency medical care on my/the patient's behalf is necessary, and that refusal of recommended care and transport to a hospital facility may result in death, or imperil my/the patient's health by increasing the opportunity for consequences or complications. Nevertheless, and understanding all of the above, I (or my guardian), refuse to accept emergency medical care or transport to a hospital facility, assume all risks and consequences resulting from my (or my guardian's) decision, and release Pinellas County EMS from any and all liability resulting from my (or my guardian's) refusal. I have had the opportunity to ask all of the questions I feel necessary to provide this informed refusal.

Lisa only signed her name, checked the Patient box (rather than Guardian), and wrote her phone number, 559-9886. She did not fill in an address.

There are notes written on the reverse side that have bled through; they are very hard to read, but appear to include the comments: "PT states she needs to talk ... people think she was crazy. Pt has agitated state ... Pt states she is Scientologist. ... Cont to ask me ... "

This is probably the Refusal form mentioned in the police interview with paramedic Bonnie Portolano<.

continuation of the PINELLAS C0UNTY EMS PATIENT CARE REPORT

There are no items marked in the following sections of the form:

  • Airway Interventions
  • Breathing Interventions
  • Circulation Interventions
  • Fluids
  • Secondary Interventions
  • Medications
TIME P R BP RHYTHM S2O1 TREATMENT DOSE ROUTE COMMENTS/RESPONSE
1825 ST EKG 0 ectopy
1822 112 18 142/90 OO 600
1835 108 18 130/86 SH 604

There are no items checked under (medical) History.

Current Meds: None

Allerlgies: None Known

Chief Complaint: "I need help, I need to talk to someone"

Narrative: 36 y/o WF involved in minor MVA. No injuries pt signed refusal. As we were leaving pt came walking down the road naked. We guided pt in unit. Pt stated she needs to talk, that she didn't need a body to live, stated she's an O.T., stated she took her clothes off to make people think she was crazy. Pt has a fixed stare, speak in a programmed & formal manner. Pt stated she is a scientologist, is clear, +=, EKG ST, pupils WNC, O JVD, pt switches topics as she speaks unable to stay focused on one topic. Cont to ask me to repeat the question. R/O behavioral disorder

Lead Crew Signature: Bonita Portolano

Destination Address: MPH (Morton Plant Hospital)

Hospital Selection: Nearest Facility

Response Code: ALS

Moved to Ambulance: Stretcher

Transport Position: Head Elevated

Oxygen Supplied: N

Patient: 901 Oceola #205 Clwr FL 34616

Patient Phone: 559-9886

Patient SS #: 461-94-2009

Guarantor Name, Last, First: McPherson, Lisa

Guarantor Address: SAA

Worker's Comp: N

Hospice: N

Employer Company Name: AMC Publishing<

Employer Phone #: 446-1100

Employer Company Address: XXXX Lakeview 34616