NON-TRANSPORT Patient Refusals Cancellations Documentation Liability Release Form
Policy and Procedure Upon acceptance of a call the responders will assume that the patient wishes to be transported to the hospital At no time will the responder attempt to talk the patient into not going to the hospital or going to the hospital by private vehicle. If the patient does not want to be transported they may refuse based on the County written protocol S1-13.
Policy and Procedure In simple cases, the highest level county medical responder (assuming no paramedic responded) is responsible for assessing the patient, determining that the patient is competent to refuse and obtaining a patient refusal. You must feel comfortable with the decision making process. In more complicated cases, if the first arriving unit has only BLS providers, the transport paramedic is responsible for assuring the above criteria has been met and obtain the patient refusal.
Patient Contact What is patient contact? When is patient contact made? Can we cancel without completing our own patient assessment or run report?
Protocol The patient must meet all the criteria outlined in the County Protocols. In addition to the criteria the Patient “must demonstrate an understanding of their medical situation and the risks associated with refusal.” “All cases resulting in non-transport will generate a thorough patient care narrative for each patient seen.”
Documentation The senior EMS county responder is responsible for completing all documentation for all patients on non-transports. Complete all patient demographic information as appropriate. For any call that patient contact has been established a thorough narrative must be completed using the dCHARTe format.
Documentation Objective and logical “Documentation is your best defense.” “Documentation must prove ON IT’S FACE, IN WRITING the patient’s then-present CAPACITY to understand and appreciate fully the nature of his condition, the choices available to him, and the possible consequences of refusal.” Gene Gandy
Documentation Document on the run report that you read the appropriate section of the liability release to the patient and the patient understood. On the run report patient signature line, write “see liability release.”
Documentation For any call that EMS arrives on scene and patient contact is not established you must document all the circumstances. – No patient found – Fire/Police department cancellation (document what they tell you) Document reasons for prolonged scene times. – Assure that the patient is/will be assessed by a qualified provider.
Remember First and foremost think about what is best for your patient. Always assume that every call has the potential for litigation and document accordingly.