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All profile settings can be adjusted later in Settings.
Form type
Only visual observations are available. Unchecked items are documented as not assessed.
These observations do not imply a physical examination was performed.
Select all that apply. Document care the patient accepted separately.
Location
Quick choices apply only to this narrative.
Interfacility transfer
Document the sending facility’s report separately from your own assessment. Use staff roles, not names. Room/bed references are optional; do not enter patient identifiers.
Encounter
Quantitative vital signs are intentionally excluded. Amber prompts identify required fields that still need completion. Change required fields in Settings.
Patient-reported history
Add the patient’s account when relevant.
Assessment findings
Review the default findings. Uncheck any that do not apply and enter the actual findings or “Not assessed.”
Review all selected findings and enter any missing alternate findings.
On-scene treatment
Treatment text is still entered. Uncheck “No treatments were provided” to review or clear it.
Movement to the stretcher
Customize movement methods in Settings.
Customize patient positions in Settings.
En-route treatment and response
En-route treatment text is still entered. Uncheck “No further care provided” to review or clear it.
Select if interventions started on scene were monitored and maintained during transport.
Destination and transfer of care
Care before refusal
Refusal documentation
Enter the declining party’s role or relationship, not their name. A/O and GCS alone do not establish decision-making capacity. Document only discussions and actions that occurred.
Starter wording follows the original refusal narrative and is editable. Confirm the declining person and signer for minors. Keep only statements that accurately describe what occurred; recorded A/O and GCS scores do not establish capacity.
Use roles or relationships only, not names. An alternate signer entry does not imply that a signature was obtained.
Applies only to this narrative. Change the profile default in Settings.
Generated narrative
0 words · Editable before copying
Settings
Reusable profile values. Changes are local until exported.
Install the waiting Third Writer release when you are ready.
PHI and PII: what not to enter
Reference reviewed September 12, 2026. This is a practical privacy warning, not legal advice.
HIPAA protected health information
HIPAA protects individually identifiable health information held or transmitted by covered entities or business associates when it relates to health, care, or payment. Under the Safe Harbor method, the following identifiers must be removed from health information:
- Names
- Geography smaller than a state, subject to limited ZIP-code rules
- Dates directly related to a person other than year, plus ages over 89
- Telephone numbers
- Fax numbers
- Email addresses
- Social Security numbers
- Medical record numbers
- Health-plan beneficiary numbers
- Account numbers
- Certificate or license numbers
- Vehicle identifiers and license plates
- Device identifiers and serial numbers
- Web URLs
- IP addresses
- Biometric identifiers, including finger and voice prints
- Full-face photographs and comparable images
- Any other unique identifying number, characteristic, or code
Broader PII and Texas definitions
There is no single universal U.S. legal definition of PII. NIST broadly treats PII as information that distinguishes or traces identity, alone or combined with linked information. Texas laws additionally define “personal identifying information” and “personal data” for their own scopes, including linked or reasonably linkable information and specified identifiers. Clinical details, unusual circumstances, employer/location clues, timestamps, relatives, and combinations of otherwise ordinary facts can identify someone even when a name is absent.