Documentation/patient Refusal

Question 1

GCS Scale

Answer 1

Eye opening (4-spontaneous, 3-speech, 2- pain, 1- none)
Verbal Response (5- oriented, 4- confused conversation, 3- inappropriate words, 2- incomprehensible words, 1- none)
Motor Response (6- obey commands, 5- localized pain, 4- withdraws from pain (normal flexion), 3- abnormal flexion (decordicate), 2- extension (decerebate), 1- none)

Question 2

Physical Findings and what to mark as “unremarkable”

Answer 2

Head: PEARRL, no DCAPBTLS, Airway patent
Neck: no DCAPBTLS, no midline trachea deviation
Chest: equal chest rise/fall, lungs clear and equal bilateral, no DCAPBTLS
Abdomen: soft, non-tender, no DCAPBTLS
Pelvis: stable, no DCAPBTLS
Back: no DCAPBTLS
Extremities: strong, regular pulse, full ROM, cap. refill < 2 sec., no DCAPBTLS

Question 3

Pertinent negative…

Answer 3

Chest Pain: difficulty breathing, diaphoretic, nausea, back pain, extremity pain, jaw pain, abdominal discomfort, weakness, dizziness, AMS
Difficulty Breathing: CP, dizziness, light-headedness, syncope, edema in lower extremities, headache, AMS
Headache: dizziness, light-headedness, sensitivity to light, blurry vision, nausea, nech stiffness, AMS
Abdominal Pain: nausea, vomiting, diarrhea, difficulty urinating, blood in stool/urine, AMS
Allergic Reactions: itchy, rash, hives, difficulty breathing, stridor, AMS, diarrhea, abdominal discomfort, headache
Generalized Weakness: AMS, Cincinnati Storke Scale, headache, etc. (this one has a lot more)

Question 4

OPQRST

Answer 4

Onset, Provocation, Quality, Radiation, Severity, Time

Question 5

12 Steps of a refusal

Answer 5

Know it, pg 7